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Gallbladder Volvulus as a Complication of Percutaneous Manipulation
I
Case Report
Gallbladder Volvulus as a Complication of Percutaneous Manipulation1 Rodney K. Cave, MD2 Steven C. Rose, MD Franklin J. Miller, MD
.
Index terms: Gallbladder, abnormalities, 762.458 Gallbladder, calculi, 762.289 JVIR 1990; 1:117-119
This case report concerns volvulus of the gallbladder as a complication of percutaneous manipulation. Partial reduction of the volvulus was achieved by means of catheter manipulation.
P m c u m m o u s gallstone removal has been used as an alternative method for the treatment of cholelithiasis (1,2). In this case study, gallstone removal was performed without difficulty, but during placement of a cholecystostomy tube, torsion of the gallbladder occurred (3). CASE REPORT
From the Department of Radiology, University of Utah Medical Center, 50 N Medical Dr, Salt Lake City, UT 84132. Received May 18,1990; revision requested June 12; revision received August 27; accepted August 28. Address reprint requests to S.C.R. Current address: Muskogee Radiological Group, Muskogee, Okla.
@ SCVIR, 1990
A 65-year-old white woman had a 1year history of colicky right upper quadrant pain precipitated by the ingestion of fatty foods. An ultrasound (US) scan from another institution demonstrated a 22-mm gallstone. The patient declined surgery and was referred to our hospital for possible extracorporeal shock wave lithotripsy (ESWL). A repeat US scan of the gallbladder and an oral cholecystogram obtained at our institution helped confirm the presence of a single 18 X 22-mm gallstone (Fig 1).However, the gallstone was partially calcified and, therefore, was not a candidate for the ESWL protocol. The patient elected to undergo percutaneous removal of the gallstone with rotary blade fragmentation. A rotary blade fragmentation device was percutaneously placed within the gallbladder lumen under fluoroscopic guidance. The single gallstone was successfully fragmented under fluoroscopic observation with no complications. Also with fluoroscopic guidance, a 10-F cholecystostomy drainage tube was then placed, as is routinely done in this procedure. The 10-F cholecystostomy catheter did not advance easily over an Amplatz Superstiff guide wire (Cook, Bloomington, Ind). During this step, the guide wire was noted to shift abruptly
Figure 1. Anteroposterior (AP) oral cholecystogram obtained with the patient in an upright position 1 week prior to contact lithotripsy with a rotary blade. A single, partially calcified gallstone was present within an otherwise normal-appearing gallbladder.
to the left. A follow-up spot radiograph demonstrated torsion at the neck of the gallbladder, with the gallbladder body rotated approximately 180' clockwise, relative to the gallbladder neck (Fig 2). Partial counterclockwise rotation of the gallbladder was achieved by passing a heavy-duty guide wire down the longitudinal axis of the gallbladder into the cystic duct. A 6.5-F Cobra catheter (Cook) was then inserted so that the catheter tip crossed the guide wire near the cystic duct. The secondary curve of the catheter was applied against the gallbladder wall. By using the heavyduty guide wire for leverage, the cathe-
118
Journal of Vascular and Interventional Radiology
November 1990
Figure 4. Direct cholecystogram, left anterior oblique projection, obtained on the 8th day after the procedure shows continued resolution of the gallbladder edema and collar associated with the point of rotation (arrows).
Figure 2. Intraprocedural cholecystogram in an AP projection shows partial torsion of the gallbladder after difficult guide wire manipulation and placement of the cholecystostomy drain (arrowheads). The point of rotation is the radiolucent collar a t the junction of the neck and body of the gallbladder (arrows).
ter was torqued counterclockwise, opposite the direction of the volvulus. Partial reduction of the volvulus occurred with this technique (Fig 3). A 10-F VTC drainage catheter (Meditech/Boston Scientific, Watertown, Mass) was left to enable dependent drainage, and the patient was given parenterally administered antibiotics. Within 24 hours, she developed mild right upper quadrant tenderness and mild tachycardia. Her white blood cell count was elevated to 13,000, with 81% polymorphonuclear forms. Since the clinical findings were believed to be caused by gallbladder ischemia, cholecystectomy was recommended to the patient, but she refused surgery. Approximately 36 hours after the procedure, the patient's symptoms resolved. Laboratory tests were repeated, and results revealed a normal white blood cell count. The patient was discharged approximately 72 hours after the procedure. She has remained
Figure 3. Intraprocedural cholecystogram, AP view, obtained immediately after reduction of the volvulus. The gallbladder body has a more normal orientation with respect to the gallbladder neck; the fundus is displaced medially by the drainage catheter and safety guide wire. The radiolucent collar a t the point of rotation (arrows) is less evident.
asymptomatic during the ensuant follow-up period of 8 months (Figs 4,5).
DISCUSSION Torsion of the gallbladder is a rare clinical event. Approximately 300 cases have been reported in the literature since the initial description by Wendel in 1898 (4,5). Patients usually have epigastric or right upper quadrant pain and a low-grade fever with mild leukocytosis (4). The peak prevalence is between 60 and 80 years of age with a female-to-male ratio of 3:l. According to Stieber and Bauer (4), the one predisposing factor that must exist for the gallbladder to undergo torsion is the presence of an abnormally mobile gallbladder. In the case presented, gallbladder torsion resulted from the torque on the
Figure 5. Oral cholecystogram, AP view, obtained 2 months after the procedure shows a normal, stone-free gallbladder.
gallbladder caused by guide wire manipulation during placement of a drainage catheter. Since the torsion occurred near the junction of the neck and body of the gallbladder rather than at the cystic duct, the gallbladder was probably partially attached to the liver. Partial attachment would also explain why in this case the gallbladder did not appear abnormally mobile on the oral cho-
Cave et a1
119
Volume 1 Number 1
lecystogram obtained before the procedure with the patient in an upright position. In summary, percutaneous manipulation of the gallbladder is likely to be used more frequently in the future. Since volvulus is a potential complication, careful fluoroscopic observation of gallbladder manipulations may help prevent inadvertent gallbladder volvulus. Specifically, we would recommend caution with use of stiff guide wires or catheters, particularly if resistance to forward catheter movement is encountered. Also, avoidance of excessive over-
rotation within the gallbladder should re vent the volvulus seen in this case. If ;olvulus does occur, the technique described above can allow nonoperative treatment of this complication. References 1. Picus D, Marx MV, Hicks ME, Lang EV,
Emondowicz SA. Percutaneous cholecystolithotomy: preliminary experience and technical considerations. Radiology 1989; 173:487-491. 2. Martin EC, Getrajdman GI. Does the gallbladder have a future? Radiology 1989; 170:969-973. 3. Miller FJ, Kensey KR, Nash JE. Ex-
perimental percutaneous gallstone lithotripsy: results in swine. Radiology 1989; 170:985-987. Stieber AC, Bauer JJ. Volvulus of the gallbladder. Am J Gastroenterol 1983; 78:96-98. Wendel AV. A case of floating gallbladder and kidney complicated by cholelithiasis with perforation of the gallbladder. Ann Surg 1898; 27:199-202.
Case Report
Gallbladder Volvulus as a Complication of Percutaneous Manipulation1 Rodney K. Cave, MD2 Steven C. Rose, MD Franklin J. Miller, MD
.
Index terms: Gallbladder, abnormalities, 762.458 Gallbladder, calculi, 762.289 JVIR 1990; 1:117-119
This case report concerns volvulus of the gallbladder as a complication of percutaneous manipulation. Partial reduction of the volvulus was achieved by means of catheter manipulation.
P m c u m m o u s gallstone removal has been used as an alternative method for the treatment of cholelithiasis (1,2). In this case study, gallstone removal was performed without difficulty, but during placement of a cholecystostomy tube, torsion of the gallbladder occurred (3). CASE REPORT
From the Department of Radiology, University of Utah Medical Center, 50 N Medical Dr, Salt Lake City, UT 84132. Received May 18,1990; revision requested June 12; revision received August 27; accepted August 28. Address reprint requests to S.C.R. Current address: Muskogee Radiological Group, Muskogee, Okla.
@ SCVIR, 1990
A 65-year-old white woman had a 1year history of colicky right upper quadrant pain precipitated by the ingestion of fatty foods. An ultrasound (US) scan from another institution demonstrated a 22-mm gallstone. The patient declined surgery and was referred to our hospital for possible extracorporeal shock wave lithotripsy (ESWL). A repeat US scan of the gallbladder and an oral cholecystogram obtained at our institution helped confirm the presence of a single 18 X 22-mm gallstone (Fig 1).However, the gallstone was partially calcified and, therefore, was not a candidate for the ESWL protocol. The patient elected to undergo percutaneous removal of the gallstone with rotary blade fragmentation. A rotary blade fragmentation device was percutaneously placed within the gallbladder lumen under fluoroscopic guidance. The single gallstone was successfully fragmented under fluoroscopic observation with no complications. Also with fluoroscopic guidance, a 10-F cholecystostomy drainage tube was then placed, as is routinely done in this procedure. The 10-F cholecystostomy catheter did not advance easily over an Amplatz Superstiff guide wire (Cook, Bloomington, Ind). During this step, the guide wire was noted to shift abruptly
Figure 1. Anteroposterior (AP) oral cholecystogram obtained with the patient in an upright position 1 week prior to contact lithotripsy with a rotary blade. A single, partially calcified gallstone was present within an otherwise normal-appearing gallbladder.
to the left. A follow-up spot radiograph demonstrated torsion at the neck of the gallbladder, with the gallbladder body rotated approximately 180' clockwise, relative to the gallbladder neck (Fig 2). Partial counterclockwise rotation of the gallbladder was achieved by passing a heavy-duty guide wire down the longitudinal axis of the gallbladder into the cystic duct. A 6.5-F Cobra catheter (Cook) was then inserted so that the catheter tip crossed the guide wire near the cystic duct. The secondary curve of the catheter was applied against the gallbladder wall. By using the heavyduty guide wire for leverage, the cathe-
118
Journal of Vascular and Interventional Radiology
November 1990
Figure 4. Direct cholecystogram, left anterior oblique projection, obtained on the 8th day after the procedure shows continued resolution of the gallbladder edema and collar associated with the point of rotation (arrows).
Figure 2. Intraprocedural cholecystogram in an AP projection shows partial torsion of the gallbladder after difficult guide wire manipulation and placement of the cholecystostomy drain (arrowheads). The point of rotation is the radiolucent collar a t the junction of the neck and body of the gallbladder (arrows).
ter was torqued counterclockwise, opposite the direction of the volvulus. Partial reduction of the volvulus occurred with this technique (Fig 3). A 10-F VTC drainage catheter (Meditech/Boston Scientific, Watertown, Mass) was left to enable dependent drainage, and the patient was given parenterally administered antibiotics. Within 24 hours, she developed mild right upper quadrant tenderness and mild tachycardia. Her white blood cell count was elevated to 13,000, with 81% polymorphonuclear forms. Since the clinical findings were believed to be caused by gallbladder ischemia, cholecystectomy was recommended to the patient, but she refused surgery. Approximately 36 hours after the procedure, the patient's symptoms resolved. Laboratory tests were repeated, and results revealed a normal white blood cell count. The patient was discharged approximately 72 hours after the procedure. She has remained
Figure 3. Intraprocedural cholecystogram, AP view, obtained immediately after reduction of the volvulus. The gallbladder body has a more normal orientation with respect to the gallbladder neck; the fundus is displaced medially by the drainage catheter and safety guide wire. The radiolucent collar a t the point of rotation (arrows) is less evident.
asymptomatic during the ensuant follow-up period of 8 months (Figs 4,5).
DISCUSSION Torsion of the gallbladder is a rare clinical event. Approximately 300 cases have been reported in the literature since the initial description by Wendel in 1898 (4,5). Patients usually have epigastric or right upper quadrant pain and a low-grade fever with mild leukocytosis (4). The peak prevalence is between 60 and 80 years of age with a female-to-male ratio of 3:l. According to Stieber and Bauer (4), the one predisposing factor that must exist for the gallbladder to undergo torsion is the presence of an abnormally mobile gallbladder. In the case presented, gallbladder torsion resulted from the torque on the
Figure 5. Oral cholecystogram, AP view, obtained 2 months after the procedure shows a normal, stone-free gallbladder.
gallbladder caused by guide wire manipulation during placement of a drainage catheter. Since the torsion occurred near the junction of the neck and body of the gallbladder rather than at the cystic duct, the gallbladder was probably partially attached to the liver. Partial attachment would also explain why in this case the gallbladder did not appear abnormally mobile on the oral cho-
Cave et a1
119
Volume 1 Number 1
lecystogram obtained before the procedure with the patient in an upright position. In summary, percutaneous manipulation of the gallbladder is likely to be used more frequently in the future. Since volvulus is a potential complication, careful fluoroscopic observation of gallbladder manipulations may help prevent inadvertent gallbladder volvulus. Specifically, we would recommend caution with use of stiff guide wires or catheters, particularly if resistance to forward catheter movement is encountered. Also, avoidance of excessive over-
rotation within the gallbladder should re vent the volvulus seen in this case. If ;olvulus does occur, the technique described above can allow nonoperative treatment of this complication. References 1. Picus D, Marx MV, Hicks ME, Lang EV,
Emondowicz SA. Percutaneous cholecystolithotomy: preliminary experience and technical considerations. Radiology 1989; 173:487-491. 2. Martin EC, Getrajdman GI. Does the gallbladder have a future? Radiology 1989; 170:969-973. 3. Miller FJ, Kensey KR, Nash JE. Ex-
perimental percutaneous gallstone lithotripsy: results in swine. Radiology 1989; 170:985-987. Stieber AC, Bauer JJ. Volvulus of the gallbladder. Am J Gastroenterol 1983; 78:96-98. Wendel AV. A case of floating gallbladder and kidney complicated by cholelithiasis with perforation of the gallbladder. Ann Surg 1898; 27:199-202.