Diagnosis and laparoscopic approach to gallbladder torsion and cholelithiasis

Gallbladder volvulus diagnosed intraoperatively: Case report

INTRODUCTION

Gallbladder volvulus is a rare disease whose presentation usually overlaps with that of typical calculous cholecystitis. It's diagnosis is critical as it is associated with high morbidity and mortality and therefore should be managed urgently with cholecystectomy.

CASE PRESENTATION

85-year-old female patient presented with right upper quadrant pain of one day duration that is associated with nausea and vomiting, but no fever or jaundice. She was tachycardiac and had severe abdominal right upper quadrant tenderness with positive Murphy's sign. Laboratory results showed only increase in inflammatory markers. Both ultrasound and computed tomography scan of the abdomen were done and acalculous cholecystitis was diagnosed. Open cholecystectomy was planned and performed, but gallbladder volvulus as the cause of cholecystitis was noted intraoperatively.

DISCUSSION

There is still no consensus on the exact cause of gallbladder volvulus. Even though it presents mostly in elderly patients, different ages have been already reported. It's diagnosis can be suspected based on the appearance, symptoms, and examination of the patient. Laboratory tests and imaging might provide some clues for it's diagnoses. It's ischemic process prompts urgent surgical intervention and does not improve conservatively. Our patient did not present with all of it's typical symptoms and the diagnosis was made intraoperatively.

CONCLUSION

Gallbladder volvulus could have been missed had we not opt for an urgent surgery. More studies should be done to further define its presentation, and accurately know when to consider it up in our differential diagnosis.

Gallbladder Volvulus in an Elderly Female With Severe Kyphoscoliosis

Gallbladder volvulus is a very rare complication of a congenital defect in gallbladder development also known as a "floating" gallbladder and often presents in the elderly. Proposed aetiologies include loss of abdominal fat and kyphoscoliosis. We present a patient with severe lumbar scoliosis centred on L2, producing a lumbar vertebral distortion of about 30 degrees concave to the right, resulting in right hemiabdomen volume loss. The mechanical interaction between the gallbladder fundus and compressed viscera transmits abnormal ambulatory forces from the distorted right pelvic brim into the abdomen predisposing to gallbladder torsion. Laparoscopic cholecystectomy was performed without complication and the patient had an uneventful recovery. This case demonstrates the challenges of diagnosing gallbladder torsion preoperatively. A high level of clinical suspicion is vital especially in elderly patients to enable timely surgical intervention to reduce morbidity and mortality.

Gallbladder Volvulus: A Review

Gallbladder volvulus is an uncommon condition that mostly affects older women. The cause of gallbladder volvulus is unknown, although intraoperative evidence of a floating gallbladder with a twisting of its pedicle, resulting in gallbladder ischemia, may lead to subsequent complications. Gallbladder volvulus symptoms are similar to acute cholecystitis, leading to delayed diagnosis and treatment. Early detection and prompt surgical intervention are critical for reducing morbidity and mortality. Even though numerous case reports have been published since 1898, gallbladder volvulus remains challenging to diagnose preoperatively. As a result, a high level of suspicion is required to prompt cholecystectomy and avoid further complications. We review the etiology, pathophysiology, clinical manifestation, diagnostic strategies, and treatment of this disease.

An Unusual Presentation of Acute Cholecystitis due to a Gallbladder Volvulus in a Young Female: A Case Report and Review of the Literature

The gallbladder volvulus is a rare entity of acute abdomen and a life-threatening condition that requires urgent surgery. The etiology of gallbladder volvulus is still unclear, and there is intraoperative evidence of a floating gallbladder that leads to a twisting of its pedicle, thus causing gallbladder ischemia and necrosis. Gallbladder volvulus is more frequently encounter in elderly females. We report a case of a 27-year-old female who presented with a clinical manifestation consistent with acute cholecystitis. Radiologic finding demonstrated displacement of the gallbladder body and fundus from the gallbladder fossa into the gastrohepatic recess. An emergency laparoscopic cholecystectomy was performed, and intraoperative findings revealed a gangrenous free-floating gallbladder that displaced to the dorsal sector of the left lobe liver. The critical view of safety was able to identify clearly and the gallbladder was removed safely with laparoscopic approach. While many previous cases have been reported, diagnosis of gallbladder volvulus remains difficult especially in young adults. Prompt diagnosis and surgery in cases of acute cholecystitis due to gallbladder volvulus are important to avoid gallbladder necrosis and perforation and result in a good outcome.

Gallbladder Volvulus: An Uncommon Twist in Biliary Pathology

Gallbladder volvulus (GBV) is an extremely rare disease, which presents similarly to acute cholecystitis. It has an incidence of less than 0.1% among urgent cholecystectomies and one in 356,000 hospital admissions. We report the case of a 92-year-old female with a three-day history of abdominal pain that had acutely worsened and localized to the right upper quadrant over the past 24 hours. Physical examination revealed a tender palpable mass in the right upper quadrant. Laboratory investigations demonstrated elevation of the white cell count and liver enzymes while CT abdomen showed a thick-walled gallbladder with an abrupt cut-off of the cystic duct suggestive of gallbladder volvulus. A laparoscopic cholecystectomy revealed a massively distended gangrenous gallbladder which has volved on the hepatocystic ligament. We present this case to demonstrate the radiological and intraoperative findings of GBV and to highlight the importance of early intervention to avoid life-threatening complications.

The diagnostic dilemma of a gallbladder volvulus: An unusual case report and review of the literature

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Gallbladder volvulus is a challenging radiological diagnosis.

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Hepatobiliary iminodiacetic acid (HIDA) scans demonstrate no filling of the gallbladder in gallbladder volvulus.

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Persisting cholecystitis symptoms in the absence of gallstones can be indicative of gallbladder volvulus.

Introduction and importance

A gallbladder volvulus is a rare medical condition requiring emergency surgery. There are 500 cases reported in the literature, and only 10 % have ever been diagnosed preoperatively. Gallbladder volvulus occurs when the gallbladder torts around the cystic duct and cystic artery resulting in occlusion of both structures and consequently, ischemia of the gallbladder. The diagnosis is challenging because the symptoms mimic cholecystitis without distinct radiological features specific for a volvulus.

Case presentation

In this article, we report the case of a 77-year-old female who underwent ultrasonography (US), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and cholescintigraphy, which all reported features of cholecystitis. She underwent a cholecystectomy on admission day 5 because of refractory pain despite treatment with intravenous antibiotics. Intraoperatively, she was discovered to have complete gallbladder torsion with gangrene. Post-operatively, she had immediate and complete resolution of pain, and made a rapid recovery.

Clinical discussion

We review the available literature to determine radiological characteristics specific to a gallbladder volvulus. Patients without cholelithiasis and incomplete filling of the gallbladder in a nuclear medicine scan should be evaluated for gallbladder volvulus.

Conclusion

Through this report, we suggest a high index of suspicion for gallbladder volvulus in elderly female patients with signs and symptoms of acalculous cholecystitis that have no resolution in symptoms with conservative management.

Gallbladder volvulus, a rare cause of acute abdomen, a case report

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Gallbladder volvulus is a rare life-threatening surgical emergency that requires emergency surgical treatment.

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Although recent advances in radiographic studies have helped in the diagnosis of many diseases, radiographic studies remain nonspecific in diagnosing volvulus of the gallbladder.

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The performance of urgent laparoscopic surgery would be first option to avoid perforation and peritonitis. With prompt surgical intervention, the condition has an excellent prognosis.

Introduction

The gallbladder volvulus is a rare surgical emergency and its defined as the rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. Definitive diagnosis is usually made during surgery and a delay in treatment may result in a high mortality due to rupture of gall bladder and bile peritonitis.

Case presentation

We report the case of an 88-year-old woman who presented with an acute torsion of gall bladder, which was treated promptly after admission by laparoscopic cholecystectomy.

Discussion

Acute torsion of gall bladder is a rare disease. Its pathogenesis is not well known but postulated to be multifactorial. Two anatomic variants that predispose to gall bladder torsion have been described. Clinical presentation is not specific, with symptoms and biologic signs that mimic acute cholecystitis.

This condition should be suspected in elderly women with uncertain diagnosis of acute cholecystitis or acute abdominal pain of unknown origin.

Conclusion

Gallbladder volvulus is a rare life-threatening surgical emergency that requires emergency surgical treatment. Out- come is often favorable when early diagnosis and surgery are made.

An unusual presentation of acute cholecystitis: gallbladder volvulus

Gallbladder volvulus is a rare condition with similar presentation to acute cholecystitis. It is caused by the gallbladder twisting upon its mesentery leading to potential ischemia and biliary obstruction. A 77-year-old female presented with symptoms of right upper quadrant pain and nausea. She was found to have an elevated leukocytosis and a palpable right upper quadrant abdominal mass on exam. Imaging revealed a severely distended gallbladder with pericholecystic fluid and wall thickening without gallstones. Intraoperatively, an extremely distended, ischemic gallbladder was noted to have twisted upon its mesentery. The structures were able to be identified and the gallbladder was able to be safely removed with a laparoscopic approach despite its large size. Gallbladder volvulus is important to consider in the differential of acute cholecystitis because delay in intervention could lead to gallbladder necrosis and possible perforation, increasing the patient’s morbidity and mortality.

Gallbladder volvulus in a patient with chronic lymphocytic leukemia treated with laparoscopic cholecystectomy

Gallbladder volvulus is a rare condition that most commonly occurs in elderly women and often mimics acute cholecystitis in its presentation. This condition is a surgical emergency requiring cholecystectomy as it can lead to gallbladder perforation and bilious peritonitis with high morbidity to the patient. An 85-year-old woman with chronic lymphocytic leukemia presented with acute-onset right upper-quadrant abdominal pain and associated nausea with emesis. After admission to the surgical service and initiation of intravenous antibiotics, the patient was taken to the operating room for surgical management due to the persistence of symptoms. Intraoperative findings included a necrotic appearing gallbladder that was twisted on the cystic duct. Laparoscopic cholecystectomy was performed, which was complicated by bile leak requiring endoscopic retrograde cholangiopancreatography with bile duct stenting followed by operative washout. Gallbladder volvulus can be challenging to diagnose. This condition should be suspected in elderly women with acute-onset abdominal pain and imaging concerning for acute cholecystitis. Emergent cholecystectomy is the treatment of choice for gallbladder volvulus.

Rare case report of acalculous cholecystitis: Gallbladder torsion resulting in rupture

Acalculous cholecystitis caused by gallbladder torsion is a rare condition. Only 500 cases have been reported since the first diagnosed case in 1898. We present the case of a 89-year-old woman with sudden onset of severe epigastric pain, radiating across her right costal margin, associated with nausea. Her abdomen was soft, mildly distended, Murphy’s negative but with epigastric tenderness and palpable mass. Computed tomography and ultrasound demonstrated significant acute cholecystitis, with the common bile duct measuring 7 mm. Due to the patients’ comorbidities, conservative treatment was initiated, until she was becoming increasing worse, so a laparoscopic cholecystectomy was performed. The operation revealed gallbladder torsion causing complete gallbladder necrosis and perforation with intraperitoneal biliary spillage. Gallbladder torsion should be a high differential if an elderly female patient presenting with sudden onset of abdominal pain, tender epigastric/right upper quadrant mass and a distended gallbladder on imaging. A laparoscopic cholecystectomy must be performed promptly to reduce the likelihood of gallbladder rupture and reduce the mortality and morbidity associated with this condition.

Single-Institution Case Series of Patients Undergoing Cholecystectomy for Gallbladder Torsion

Gallbladder torsion is one subtype of acute cholecystitis. Because of the very low incidence of the condition, there are few reports analyzing multiple cases of gallbladder torsion. The preoperative diagnosis is difficult and reported to be made in only 26% of patients. Herein, we report 6 consecutive cases of gallbladder torsion in 7 years and highlight the clinical and radiologic findings that facilitate preoperative diagnosis. Between 2005 and 2011, a total of 6 patients received a diagnosis of and were treated for gallbladder torsion in Toyonaka Municipal Hospital. A total of 5 patients received a diagnosis of gallbladder torsion or were suspected of having gallbladder torsion preoperatively, and 1 additional patient was diagnosed intraoperatively. The computed tomography findings of both excessive gallbladder swelling and rotation of the gallbladder fundus were observed in 5 patients, which were indicative findings of gallbladder torsion. The remaining 1 patient received a diagnosis intraoperatively. The twisted cystic duct and artery had been observed as a “whirl sign” preoperatively in 2 patients. Emergency cholecystectomy was performed: laparoscopic cholecystectomy was performed in 4 patients and open cholecystectomy in 2 patients. The patients treated by laparoscopic approach showed more rapid recovery and shorter postoperative hospital stay before discharge. The radiologic findings of both excessive gallbladder swelling and rotation of the gallbladder fundus are indicative of gallbladder torsion. The laparoscopic cholecystectomy approach could be considered the first choice for patients with gallbladder torsion.

Complete torsion of gallbladder following laparoscopic cholecystectomy: A case study

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Accurate preoperative diagnosis of gallbladder torsion is challenging because of the absence of clinical characteristics associated with it.

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Careful attention to symptoms during clinical presentation, including acute severe pain in the right quadrant and gallbladder deviation observed during radiological investigation, is required for accurate diagnosis of the condition.

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Upon confirmation of diagnosis, laparoscopic cholecystectomy would be the gold-standard treatment option rather than open cholecystectomy.

Introduction

Gallbladder torsion is mainly associated with a floating gallbladder. From an anatomical perspective, laparoscopic cholecystectomy is a more optimal treatment than open cholecystectomy.

Presentation of case

An 84-year-old woman visited the Onomichi General Hospital because of progressive pain in the right upper quadrant of her abdomen. Physical examination revealed a positive Murphy sign and peritoneal irritation. Laboratory data demonstrated that inflammatory marker levels were increased. Abdominal ultrasonography showed that blood flow in the cystic artery was reduced and the gallbladder was swollen. Abdominal contrast-enhanced computerized tomography indicated that the swollen gallbladder was modestly enhanced and the fundus was displaced under the midline and detached from the gallbladder bed. The cystic duct was twisted. Magnetic resonance cholangiopancreatography showed that the root of the cystic duct was unclear and the extrahepatic bile duct had V-shaped distortion. The gallbladder neck showed a tapering interruption with the common biliary duct. We made a preoperative diagnosis of gallbladder torsion. Accordingly, emergency laparoscopic cholecystectomy was performed. The intraoperative findings included a dark swollen gallbladder that was twisted in the counterclockwise direction. The patient was discharged without any postoperative complications on day 7.

Discussion

Combined acute onset of abdominal pain with characteristic radiological findings made it possible to precisely diagnose gallbladder torsion.

Conclusion

Laparoscopic cholecystectomy can be the gold standard treatment for gallbladder torsion after a preoperative diagnosis is made.

[Gallbladder volvulus: Diagnostic and surgical challenges]

BACKGROUND

The gallbladder volvulus is defined as the rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery. It is an extremely rare surgical disease and definitive diagnosis is usually made during surgery.

CASE REPORT

A 78 year old woman presented with upper right quadrant abdominal pain, with no comorbidities and no other accompanying symptoms. Analysis revealed haemodynamic instability and leukocytosis. Computed tomography of abdomen showed an acute cholecystitis. During emergency right hypochondrium laparotomy, the gallbladder was found to be twisted counterclockwise with huge gangrenous gallbladder distal. Open cholecystectomy was performed and after the surgery, the patient was discharged in a few days.

CONCLUSION

Gallbladder volvulus, or gallbladder torsion, is a rare condition and should be considered when clinical and imaging findings of complicated cholecystitis are present. The performance of urgent laparoscopic surgery would be first option to avoid perforation, peritonitis and haemodynamic instability.

Gallbladder Volvulus in a Patient with Type I Choledochal Cyst: A Case Report and Review of the Literature

Introduction. Gallbladder volvulus is a rare, potentially fatal condition unless diagnosed and treated early. Choledochal cysts are rare congenital malformations of the biliary tree predisposing to different pathologies and posing the risk of degradation into cholangiocarcinoma and gallbladder cancer. Dealing with both diseases at once has not been published yet in the literature. Presentation of Case. We report a case of gallbladder volvulus in an elderly female who happened to have a concomitant type I choledochal cyst. Treatment was achieved with a cholecystectomy and observation and follow-up of the choledochal cyst. Discussion. Prompt diagnosis and surgical management of gallbladder volvulus is important to avoid the morbidity and mortality of gangrenous cholecystitis and biliary peritonitis in a frail old population of patients. Precise clinical diagnosis, supplemented with specific imaging clues, helps in the diagnosis. Management of choledochal cysts is also surgical; however the timing of surgery is still a matter of debate. Conclusion. We describe in this report the first case of gallbladder volvulus in a patient with a choledochal cyst and propose a management algorithm of a very rare biliary tree pathology combination.

Gallbladder Volvulus Presenting as Acute Appendicitis

We encountered a case of gallbladder volvulus in an 88-year-old thin female in which the initial presentation was more consistent with that of acute appendicitis. After complete work-up, including physical exam, lab work, and computed tomography, the definite diagnosis of gallbladder volvulus was not made until intraoperative visualization was obtained. Gallbladder volvulus is a rare but serious condition, which requires a high clinical suspicion so prompt surgical intervention can be undertaken.

Complete body-neck torsion of the gallbladder: A case report

Gallbladder torsion is a rare, acute abdominal disease. It was first reported by Wendell in 1898. Since then, only 500 cases have been reported. Gallbladder torsion occurs in all age groups, although it usually appears in the latter stages of life. The occurrence ratio between women and men is 3:1. Most cases are diagnosed during surgery. The main treatment is surgical detorsion and cholecystectomy. Despite progress in radiologic imaging diagnosis, it is not easy to obtain a precise preoperative diagnosis of gallbladder torsion. In previous reports, only 9.8% of all gallbladder torsion cases were diagnosed preoperatively. We present a case of acute body-neck gallbladder torsion in an elderly man, and we review the radiologic findings of magnetic resonance imaging, computed tomography, and ultrasonography. The radiologic findings in the present case were helpful in obtaining a preoperative diagnosis of gallbladder torsion. The diagnosis was confirmed by T2-weighted magnetic resonance images, which showed an intra-gallbladder segment located between the body and neck of the gallbladder, with a notable crease within this segment.

Gallbladder torsion: a diagnostic challenge

80-year-old female presented with clinical findings suggestive of acute cholecystitis. Intraoperatively we discovered a dusky gallbladder with gangrenous patches and gallbladder torsion with 270 degrees clockwise rotation along the longitudinal axis. Gallbladder torsion is a rare cause of acute cholecystitis with less than 500 cases published in the literature. Gallbladder torsion should be included in the list of differential diagnoses in patients suspected of having acute cholecystitis especially when there are inconsistencies between clinical features and imaging. It is worth noting that 3-dimensional reconstructed CT may be useful in preoperative diagnosis of gallbladder torsion.

A Clinician's Guide to the Diagnosis and Management of Gallbladder Volvulus

INTRODUCTION

Gallbladder volvulus (GV), or torsion of the gallbladder, is an uncommon surgical emergency. This article reviews the world literature related to GV. We examine the history of gallbladder torsion and highlight the critical constellation of presenting signs and symptoms, which guide the acute care physician and surgeon to accurate and timely diagnosis of GV before surgical intervention.

METHODS

A comprehensive review of all published cases of GV was performed using the National Library of Medicine (PubMed) database.

RESULTS

Lists of typical symptoms and clinical presentations are provided to allow clinicians to establish an accurate preoperative diagnosis.

CONCLUSION

GV is frequently undiagnosed before surgical intervention. However, clinical presentation and associated radiographic findings can lead to an accurate diagnosis if the clinician is aware of this uncommon condition. When the diagnosis has been established before operative intervention, expeditious laparoscopic cholecystectomy can be performed safely. Delays in diagnosis may mandate open cholecystectomy if laparoscopic extraction is contraindicated because of undesirable sequelae of gallbladder necrosis, specifically perforation, bilious peritonitis, and hemodynamic instability.

Gallbladder volvulus: a case of mimicry

Torsion of the gallbladder resulting in a volvulus is a rare clinical finding that poses a diagnostic challenge preoperatively to both surgeons and radiologists. It is thought to occur secondary to a redundant mesentery where rotation of the gallbladder occurs along the axis of the cystic duct and cystic artery. Gallbladder volvulus commonly presents as acute cholecystitis and is rarely diagnosed preoperatively. An early emergency laparoscopic cholecystectomy is the preferred treatment. Early consideration of this diagnosis enables prompt surgical intervention and quick postoperative recovery periods.

A gallbladder torsion presenting as acute cholecystitis in an elderly woman: A case report

Introduction

Gallbladder torsion is a rare, but potentially lethal disease, in which early recognition is crucial.

Case presentation

We describe the case of an 89-year-old Caucasian woman who presented with clinical symptoms suggestive of acute cholecystitis to our hospital. Radiological imaging confirmed our clinical diagnosis. At first we considered percutaneous gallbladder drainage because of her age and comorbidity, but instead performed laparoscopic cholecystectomy because of rapid clinical deterioration. During laparoscopy a necrotic gallbladder due to torsion of the gallbladder around the cystic duct was found.

Conclusion

Because percutaneous drainage could lead to further deterioration in the case of gallbladder torsion, this rare condition should be considered before performing a percutaneous drainage of cholecystitis.