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Torsion of the gallbladder: A rare cause of acute cholecystitis
The Journal of Emergency Medicine, Vol. 30, No. 4, pp. 397– 401, 2006 Copyright © 2006 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/06 $–see front matter
doi:10.1016/j.jemermed.2005.07.011
Clinical Communications
TORSION OF THE GALLBLADDER: A RARE CAUSE OF ACUTE CHOLECYSTITIS David M. Lemonick,
MD,*
Robert Garvin,
MD,†
and Howard Semins,
MD, FACS†
*Department of Emergency Medicine and †Department of General Surgery, The Western Pennsylvania Hospital, 4800 Friendship Avenue, Pittsburgh, Pennsylvania Reprint Address: David M. Lemonick, MD, 215 Harrow Drive, Pittsburgh, PA 15238
e Abstract—We present a case of acute torsion of the gallbladder in a young woman. Approximately 400 cases have been reported since 1898, mostly in elderly women, and the incidence appears to be increasing. The anatomy and pathophysiology that predispose patients to this rare surgical emergency are discussed. Several clinical and imaging findings can be used to distinguish gallbladder torsion from typical acute cholecystitis. By recognizing and treating gallbladder torsion early in its course, a low surgical morbidity and mortality can be achieved. The case presented highlights for emergency physicians some of the considerations in identification of patients with acute cholecystitis who are at highest risk of gangrene and perforation, their emergency treatment, and the timing of surgery. © 2006 Elsevier Inc.
der torsion in particular, and the recognition of the highrisk patient and the timing of surgery in acute cholecystitis in general. CASE REPORT A 36-year-old woman presented to the Emergency Department (ED) complaining of epigastric and lower chest discomfort of 6 h duration. The pain began postprandially, was pressure-like, 8/10 in intensity, and was without referral. She denied fever, nausea, vomiting, dyspnea, diaphoresis, or any previous similar episodes. The past medical history, social history, and review of systems were unremarkable. On examination, the heart rate was 100 beats/min; blood pressure was 110/60 mm Hg; respirations were 20 breaths/min; and temperature was 37°C (98.5°F). The patient appeared uncomfortable but was non-toxic, anicteric, well hydrated, and in no acute distress. The abdomen was scaphoid, with involuntary guarding and direct and rebound tenderness in the epigastrium and right upper quadrant. There was no palpable mass or organomegaly, but Murphy’s sign was elicited. Intravenous saline and ketorolac were administered with minimal improvement in the pain, and she developed nausea. Metoclopramide and fentanyl were given with prompt relief of all symptoms. She was admitted with a diagnosis of acute cholecystitis and was kept N.P.O. Laboratory examination showed a white blood cell count of 10,700/mm3, with 80% polymorphonuclear leu-
e Keywords— gallbladder; volvulus; torsion; cholecystitis; abdominal
INTRODUCTION Torsion of the gallbladder is a rare cause of acute cholecystitis that is difficult to diagnose preoperatively. This condition primarily affects elderly women, and its incidence appears to be increasing, possibly as a result of greater life expectancies. A case of acute torsion of the gallbladder in a young woman is presented, and we review the history, anatomy, pathophysiology, diagnosis and treatment of this unusual surgical emergency. For the emergency physician, this case highlights both the importance of early recognition and treatment of gallblad-
RECEIVED: 19 November 2004; FINAL ACCEPTED: 26 July 2005
SUBMISSION RECEIVED:
31 May 2005;
397
398
D. M. Lemonick et al.
Figure 1. Gallbladder ultrasound showing distention, absence of stones, and wall thickening.
Figure 3. CT scan of abdomen showing distended gallbladder with pericholecystic fluid.
kocytes and toxic granulations. Liver function tests and lipase were normal, and a urine pregnancy test was negative. Abdominal sonography showed a distended gallbladder with a wall thickness of 7 mm, and without stones. There was a small amount of pericholecystic fluid present, and the common bile duct was 4 mm in diameter (Figure 1). The ultrasonographic Murphy’s sign was positive. A hepatoiminodoacetic acid scan showed nonfilling of the gallbladder in 3.5 h (Figure 2). Approximately 9 h after admission and 15 h after the initial onset of symptoms, the patient’s pain, tenderness,
and nausea returned. Repeat abdominal examination showed diffuse direct and rebound tenderness of the right abdomen. An abdominal computed tomography (CT) scan revealed pericholecystic fluid, non-visualization of the appendix, and free pelvic fluid (Figure 3). The patient underwent exploratory laparoscopy, which revealed acute torsion of the gallbladder, a diagnosis that was not considered preoperatively. The gallbladder was freely mobile, distended, gangrenous, and without mesenteric attachments, and it was suspended only by the cystic artery and cystic duct (Figures 4, 5). Laparoscopic cholecystectomy and intraoperative cholangiogram were performed without difficulty, and the patient was discharged on postoperative day one. She made an uneventful recovery.
Figure 2. HIDA scan showing non-filling of gallbladder in 3.5 h.
Figure 4. Appearance of twisted gallbladder at laparoscopy.
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the gallbladder. The third abnormality involves a portion of the fundus of the gallbladder that is not fixed to the liver bed and may undergo torsion. In the rarest variant, a normally fixed gallbladder is attached to a mobile hepatic lobe free of its coronary and triangular ligaments. Pathophysiologic factors precipitating torsion of the gallbladder in predisposed individuals have been postulated. These include cholelitihiasis, atherosclerosis of the cystic artery, kyphoscoliosis, vigorous peristalsis of neighboring organs, violent movements, abdominal trauma, adhesions, multiparity, the postpartum state, visceroptosis, rapid weight loss, constipation, iatrogenic manipulation, sigmoid volvulus, diarrhea, and heavy meals (1,2,4,7,15). Figure 5. Neck of gallbladder demonstrating torsion of cystic artery and cystic duct, and congenital absence of mesentery.
DISCUSSION History and Demographics Gallbladder volvulus was originally described in a 25year-old pregnant woman by Wendell in 1898 (1–3). Since that time approximately 400 cases have been reported, with an estimated incidence of 1/365,520 hospital admissions (2,4 – 6). Of these, only 10 were identified preoperatively (3,7). The incidence appears to be increasing, possibly due to increased life expectancies (7,8). Although it has been reported in patients aged 2 to 100 years, the average age of incidence for gallbladder volvulus is 65–75 years. There is a 3:1 female to male sex predilection, and 84% of patients are elderly women (2,9 –13).
Etiology and Pathophysiology Gallbladder torsion is believed to occur in anatomically predisposed patients as a result of a precipitating event. It is estimated that 4% to 5% of the population is affected by an anatomic variant that could lead to gallbladder volvulus (1). Four such anatomic variants are have been identified (2,4,5,8,10,14). In the first variant, abnormal migration of the pars cystica from the hepatic diverticulum during the 4th–7th weeks of embryological development results in an absence of a gallbladder mesentery. This creates a free-floating gallbladder suspended only by the cystic duct and artery. In the second anomaly, the normally formed mesentery in an elderly patient relaxes and elongates, becoming progressively mobile. Atrophy of the liver combined with decreasing elasticity of connective tissues leads to viceroptosis, allowing torsion of
Clinical Presentation The clinical presentation of gallbladder torsion may be due either to recurrent episodes of incomplete (⬍ 180 degree) volvulus, or due to a single complete (⬎ 180 degree) volvulus of the organ (2,12). The former presents as recurrent episodes of slowly progressive pain, with variably associated nausea and vomiting. In the latter, there is an abrupt onset of severe right upper quadrant pain, early onset of nausea and vomiting, and frequently there is a palpable abdominal mass (2,8,9,12,14,16,17). Some authors have observed a clinical triad in gallbladder torsion that consists of a pulse-temperature discrepancy, a palpable right upper quadrant mass, and a lack of toxicity and jaundice (2). A mass is palpable in 20% to 30% of cases, and 20% to 50% have gallstones, in contrast to 90% with stones in typical acute cholecystitis (8,9,18). Fever and leukocytosis are inconsistently present, and it has been observed that a lower frequency of fever, leukocytosis, and jaundice, accompanied by a poor response to antibiotics, distinguishes gallbladder torsion from the usual case of acute cholecystitis (6,7,9). A preoperative diagnosis of acute gallbladder torsion is present in only 10% of cases, with the majority of cases diagnosed intraoperatively (9,10,16,18). The rate of accurate preoperative diagnosis may be expected to increase due to ever more widely available abdominal ultrasound and computed tomography (11,12,14,19).
Laboratory Evaluation There is no single reliable preoperative test for gallbladder torsion (16). The white blood cell (WBC) count is usually normal at the onset of symptoms but rises as gallbladder ischemia develops (2,8). A hypochloremic, hypokalemic metabolic alkalosis may be present (20). Liver function tests are usually normal because the com-
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mon bile duct and the hepatic ducts are not involved in gallbladder torsion, and jaundice is present less often than in typical cholecystitis (2,9,20). Preoperative imaging studies include plain films, ultrasound, color flow Doppler, endoscopic retrograde cholangiography (ERC), CT scanning, hepatoiminodoacetic acid scanning (HIDA), and magnetic resonance cholangiopancreatography (MRCP) (2,9). Plain films are considered nonspecific and insensitive in the diagnosis of gallbladder torsion (2). Ultrasound has been the most reliable of the available imaging modalities and may show a floating gallbladder with a conical or square appearance, without gallstones, with a thickened wall, and with discontinuity of the lumen to suggest volvulus [(2,8,9,13,14,17)]. A less frequent but more specific finding is a free-floating gallbladder that is not present in the liver bed (6,8). The gallbladder wall may show “thumbprinting,” which is a sign of gangrene. A notched appearance of the outer contour of the gallbladder on ultrasound has been described in torsion, as has a stretched gallbladder pedicle seen as a conical structure comprised of multiple linear echoes that converge at the tip of the cone (6,14,15). A distended gallbladder with a thickened wall and surrounded by pericholecystic fluid is common both to torsion and to common acute cholecystitis. The degree of gallbladder distension on sonogram in torsion is greater than that seen in acute cholecystitis. This is because of the chronically scarred and thus less elastic gallbladder wall due to previous inflammation in the latter condition (8). A continuous hypoechoic line in the wall of the gallbladder on ultrasound has been described and is felt to reflect a combination of venous and lymphatic stasis (5). Ninety percent of torsioned gallbladders will show edema of the wall on ultrasound or CT scan (5,9). Color flow Doppler has been found to distinguish torsion from acute cholecystitis, based upon the presence or absence of cystic artery flow (9). Hepatobiliary scanning in acute gallbladder torsion may reveal a “bull’s-eye” image, with a focal accumulation of radioactivity medial to the photopenic area that represents the nonfilling gallbladder. Also on HIDA scanning, a fusiform common bile duct has been described, as well as delayed filling of the organ that sometimes can be seen on decubitus images (2,9). None of the sonographic or nuclear scann findings suggestive of torsion was present in the patient presented. The ERC in gallbladder torsion shows a peak-shaped cystic duct originating from a normal or slightly tented common bile duct, with non-filling of the gallbladder and discontinuity from the cystic duct (9,10). A typical appearance on ERC of crossing mucosal folds has been described, and therapeutic detorsion of the gallbladder by ERC has been accomplished (8,14). MRCP may show V-shaped tenting of the extrahepatic bile ducts due to traction by the cystic duct, with
D. M. Lemonick et al.
tapering and discontinuity of the cystic duct, and differences in signal intensity from the gallbladder, cystic duct, and extrahepatic bile ducts (2). MR imaging with fat suppressed T1-weighted imaging has been useful in showing coagulation necrosis of the gallbladder wall in volvulus, and is an unusual finding in typical acute cholecystitis (10).
Differential Diagnosis A preoperative diagnosis of acute gallbladder torsion is rarely made (9 –12,18). In one large series the diagnosis was made preoperatively in only 10% of cases (9). It is anticipated that an increasing proportion of cases will be diagnosed preoperatively due to the wide availability of ultrasound and CT (11,12,14,19). The differential diagnosis of gallbladder volvulus includes acute cholecystitis, acute pancreatitis, perforated peptic ulcer, intestinal obstruction and, in cases of extreme visceroptosis, acute appendicitis (2,4,8,11). It has been stated that gallbladder volvulus must be considered in any elderly female with acute right lower quadrant pain (4).
Treatment and Implications in Emergency Medicine Although surgical detorsion and fixation of the gallbladder have been performed, cholecystectomy is now the accepted treatment for gallbladder volvulus. Laparoscopic techniques are particularly well suited to detorsion and cholecystectomy (1,2,7,8,11,12,14,16,18 –20). The timing of surgery in acute cholecystitis is beyond the usual scope of practice for emergency physicians, but this case raises some important issues. Although torsion of the gallbladder was not suspected preoperatively in the case presented, it could be argued that this patient was still a candidate for prompt cholecystectomy based upon two findings: the presence of acalculous cholecystitis, and the ultrasound results. Prompt cholecystectomy is generally recommended for patients at high risk for gangrene and perforation. These are patients with: 1) evidence of systemic toxicity (temperatures higher than 39° C or 102.2° F, a pulse rate of ⬎ 120 beats/min, and a left shift in the white blood cell count ⬎ 90% polymorphonuclear leukocytes, 2) emphysematous cholecystitis, and 3) acalculous cholecystitis (21). The latter group usually occurs in critically ill trauma and postoperative patients, especially 2 to 4 weeks after injury. The acute cholecystitis in the patient presented was acalculous, and thus should have indicated prompt surgery. Patients identified as being at high risk for gallbladder gangrene or perforation are treated with appropriate an-
Gallbladder Torsion
tibiotics (gentamycin and ampicillin, or single agents such as piperacillin, ceftriaxone, or a quinolone), and then undergo either urgent cholecystectomy or, if the surgical risk is prohibitive, percutaneous transhepatic cholecystostomy (21). Prompt cholecystectomy in this patient was also indicated by the sonogram findings. A risk score for gallbladder perforation has been devised based upon the preoperative ultrasound findings (22). Pericholecystic fluid is assigned 7 points; distention of the gallbladder, 4 points; intraluminal membrane, 4 points; round gallbladder, 3 points; intrauminal debris, 3 points; sonolucent zone in the gallbladder wall, 2 points; and a thick gallbladder wall (⬎ 3.5 mm), 1 point. A score of 12 or more points requires urgent cholecystectomy. The patient presented had pericholecystic fluid, a distended gallbladder, and a thickened gallbladder wall, for a score of 12 points, indicating the need for prompt surgical therapy.
Prognosis Factors associated with increased morbidity and mortality from torsion of the gallbladder include increased age, the presence of co-morbidities, delayed or missed diagnosis, development of gangrene, perforation, biliary peritonitis, and sepsis (1,2,8,23). In patients with complete gallbladder volvulus in whom detorsion is not accomplished, mortality approaches 100% (24). Early diagnosis and treatment of gallbladder torsion prevents gangrene and perforation, and has resulted in mortality as low as 3% to 5% (1,2,4,8,10,24 –26).
Conclusion Gallbladder torsion is a rare cause of acute cholecystitis that is seen primarily in elderly women. It results from anatomic anomalies combined with precipitating factors that predispose the gallbladder to twisting and ischemia. Without prompt diagnosis and treatment, the gallbladder becomes gangrenous and may perforate. Consideration of this rare diagnosis early in the course of acute rightsided abdominal pain and recognition of its characteristic ultrasound, nuclear scan, and CT scan findings can hasten cholecystectomy. The possibility of gallbladder torsion as a cause of acute abdominal pain reminds the emergency physician to be vigilant for those patients at highest risk for gallbladder gangrene and perforation. Thus, an acceptably low surgical morbidity and mortality can be achieved. Laparoscopic cholecystectomy is well suited to the unusual anatomy in gallbladder volvulus, and has become the preferred surgical approach to this rare emergent condition.
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REFERENCES 1. Nicholas JM. Image of the month: gallbladder volvulus. Arch Surg 2002;137:741–2. 2. Saber AA, Rosenthal RJ, Brasesco OE, et al. Gallbladder volvulus. 2002. Available at: www.emedicine.com. Accessed November 1, 2004. 3. Hendrickson RJ, Ognibene SJ, Hirokowa TI. Extra-anatomic gallbladder torsion. Am J Surg 2003;185:288. 4. Ortiz-Gonzales J, Reyes-Segura MP, Gutierrez-Carrillo F, et al. Volvulus of the gallbladder. Dig Dis Sci 2003;48:1116 –7. 5. Cameron EW, Beale TJ, Pearson RH. Case report: torsion of the gallbladder on ultrasound— differentiation from acalculous cholecystitis. Clin Radiol 1993;47:285– 6. 6. Yeh H-C, Weiss MF, Gerson CD. Torsion of the gallbladder: the ultrasonographic features. J Clin Ultrasound 1989;17:123–5. 7. Marano A, Yahchouchy-Chouillard E, Spinelli R, et al. Gallbladder torsion: report of four cases and review of the literature. Asian J Surg 2002;25:175– 8. 8. Vosswinkel JA, Colantonio AL. Torsion of the gallbladder: laparoscopic identification and treatment. Surg Endosc 1999;13: 1154 – 6. 9. Nakao A, Matsuda T, Funabiki S, et al. Gallbladder torsion: case report and review of 245 cases reported in the Japanese literature. J Hepatobiliary Pancreat Surg 1999;6:418 –21. 10. Aibe H, Honda H, Kuroiwa T, et al. Gallbladder torsion: case report. Abdom Imaging 2002;27:51–3. 11. Desmaizieres FC, Montemagno S, de Lavernette XB, et al. Torsion of the gallbladder in an adult: a rare case of acute cholecystitis. Int Surg 2002;87:87–9. 12. Rajagopal R, Rajagopal A. Acute torsion of the gallbladder. Am J Surg 2001;182:534 –5. 13. Hinoshita E, Nishizaki T, Wakasugi K, et al. Preoperative imaging can diagnose torsion of the gallbladder: report of a case. Hepatogastroenterology 1999;46:2212–5. 14. Aharoni D, Hadas-Halpern I, Fisher D, et al. Torsion of the fundus of gallbladder demonstrated on ultrasound and treated with ERCP. Abdom Imaging 2000;25:269 –71. 15. Iannelli A, Marano A, Fabiani P, et al. Minerva Chir Gallbladder torsion. A case report. 2003;58:393– 4. 16. Jarman B, Price PD, Holden C. Acute gallbladder torsion: a review and case studies. Contemp Surg 2003;59:174 – 6. 17. Quinn SF, Fazzio F, Jones E. Torsion of the gallbladder: findings on CT and sonography and role of percutaneous cholecystectomy. AJR Am J Roentgenol 1987;148:881–2. 18. Chui AKK. Commentary: gallbladder torsion. Asian J Surg 2002; 25:179. 19. Lim KT, Casey RG, Ryan JF, et al. Torsion of the gallbladder. Ir J Med Sci 2002;171:56 –9. 20. Kleiss K, Choy-Hee L, Fogle R, et al. Torsion of the gallbladder in pregnancy. A case report. J Reprod Med 2003;48:206 – 8. 21. Barkun JS, Lewis RT. Infections in the upper abdomen: biliary tract, pancreas, liver, and spleen. In: Wilmore DW, Cheung LY, Harken AH, Holcroft JW, Meakins JL, Soper NJ, eds. ACS surgery: principles and practice. New York: WebMD Corporation; 2001:1267–9. 22. Miyazaki K, Uchiyama A, Nakayama F. New approach to the timing of operative intervention for acute cholecystitis: use of ultrasound risk score (abstr). The 32nd World Congress of Surgery. Sydney, Australia: September 20 –26, 1987. 23. Whipple RD, Sabo RR. Acute torsion of the gallbladder. Am J Surg 1979;137:798 –9. 24. Losken A, Wilson BW, Sherman R. Torsion of the gallbladder: a case report and review of the literature. Am Surg 1997;63:975– 8. 25. Lal RB, Pepper M, Puestow CB. Torsion of the gallbladder. Arch Surg 1968;97:750 –2. 26. Butsch JL, Luchette F. Torsion of the gallbladder. Arch Surg 1985;120:1323.
doi:10.1016/j.jemermed.2005.07.011
Clinical Communications
TORSION OF THE GALLBLADDER: A RARE CAUSE OF ACUTE CHOLECYSTITIS David M. Lemonick,
MD,*
Robert Garvin,
MD,†
and Howard Semins,
MD, FACS†
*Department of Emergency Medicine and †Department of General Surgery, The Western Pennsylvania Hospital, 4800 Friendship Avenue, Pittsburgh, Pennsylvania Reprint Address: David M. Lemonick, MD, 215 Harrow Drive, Pittsburgh, PA 15238
e Abstract—We present a case of acute torsion of the gallbladder in a young woman. Approximately 400 cases have been reported since 1898, mostly in elderly women, and the incidence appears to be increasing. The anatomy and pathophysiology that predispose patients to this rare surgical emergency are discussed. Several clinical and imaging findings can be used to distinguish gallbladder torsion from typical acute cholecystitis. By recognizing and treating gallbladder torsion early in its course, a low surgical morbidity and mortality can be achieved. The case presented highlights for emergency physicians some of the considerations in identification of patients with acute cholecystitis who are at highest risk of gangrene and perforation, their emergency treatment, and the timing of surgery. © 2006 Elsevier Inc.
der torsion in particular, and the recognition of the highrisk patient and the timing of surgery in acute cholecystitis in general. CASE REPORT A 36-year-old woman presented to the Emergency Department (ED) complaining of epigastric and lower chest discomfort of 6 h duration. The pain began postprandially, was pressure-like, 8/10 in intensity, and was without referral. She denied fever, nausea, vomiting, dyspnea, diaphoresis, or any previous similar episodes. The past medical history, social history, and review of systems were unremarkable. On examination, the heart rate was 100 beats/min; blood pressure was 110/60 mm Hg; respirations were 20 breaths/min; and temperature was 37°C (98.5°F). The patient appeared uncomfortable but was non-toxic, anicteric, well hydrated, and in no acute distress. The abdomen was scaphoid, with involuntary guarding and direct and rebound tenderness in the epigastrium and right upper quadrant. There was no palpable mass or organomegaly, but Murphy’s sign was elicited. Intravenous saline and ketorolac were administered with minimal improvement in the pain, and she developed nausea. Metoclopramide and fentanyl were given with prompt relief of all symptoms. She was admitted with a diagnosis of acute cholecystitis and was kept N.P.O. Laboratory examination showed a white blood cell count of 10,700/mm3, with 80% polymorphonuclear leu-
e Keywords— gallbladder; volvulus; torsion; cholecystitis; abdominal
INTRODUCTION Torsion of the gallbladder is a rare cause of acute cholecystitis that is difficult to diagnose preoperatively. This condition primarily affects elderly women, and its incidence appears to be increasing, possibly as a result of greater life expectancies. A case of acute torsion of the gallbladder in a young woman is presented, and we review the history, anatomy, pathophysiology, diagnosis and treatment of this unusual surgical emergency. For the emergency physician, this case highlights both the importance of early recognition and treatment of gallblad-
RECEIVED: 19 November 2004; FINAL ACCEPTED: 26 July 2005
SUBMISSION RECEIVED:
31 May 2005;
397
398
D. M. Lemonick et al.
Figure 1. Gallbladder ultrasound showing distention, absence of stones, and wall thickening.
Figure 3. CT scan of abdomen showing distended gallbladder with pericholecystic fluid.
kocytes and toxic granulations. Liver function tests and lipase were normal, and a urine pregnancy test was negative. Abdominal sonography showed a distended gallbladder with a wall thickness of 7 mm, and without stones. There was a small amount of pericholecystic fluid present, and the common bile duct was 4 mm in diameter (Figure 1). The ultrasonographic Murphy’s sign was positive. A hepatoiminodoacetic acid scan showed nonfilling of the gallbladder in 3.5 h (Figure 2). Approximately 9 h after admission and 15 h after the initial onset of symptoms, the patient’s pain, tenderness,
and nausea returned. Repeat abdominal examination showed diffuse direct and rebound tenderness of the right abdomen. An abdominal computed tomography (CT) scan revealed pericholecystic fluid, non-visualization of the appendix, and free pelvic fluid (Figure 3). The patient underwent exploratory laparoscopy, which revealed acute torsion of the gallbladder, a diagnosis that was not considered preoperatively. The gallbladder was freely mobile, distended, gangrenous, and without mesenteric attachments, and it was suspended only by the cystic artery and cystic duct (Figures 4, 5). Laparoscopic cholecystectomy and intraoperative cholangiogram were performed without difficulty, and the patient was discharged on postoperative day one. She made an uneventful recovery.
Figure 2. HIDA scan showing non-filling of gallbladder in 3.5 h.
Figure 4. Appearance of twisted gallbladder at laparoscopy.
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the gallbladder. The third abnormality involves a portion of the fundus of the gallbladder that is not fixed to the liver bed and may undergo torsion. In the rarest variant, a normally fixed gallbladder is attached to a mobile hepatic lobe free of its coronary and triangular ligaments. Pathophysiologic factors precipitating torsion of the gallbladder in predisposed individuals have been postulated. These include cholelitihiasis, atherosclerosis of the cystic artery, kyphoscoliosis, vigorous peristalsis of neighboring organs, violent movements, abdominal trauma, adhesions, multiparity, the postpartum state, visceroptosis, rapid weight loss, constipation, iatrogenic manipulation, sigmoid volvulus, diarrhea, and heavy meals (1,2,4,7,15). Figure 5. Neck of gallbladder demonstrating torsion of cystic artery and cystic duct, and congenital absence of mesentery.
DISCUSSION History and Demographics Gallbladder volvulus was originally described in a 25year-old pregnant woman by Wendell in 1898 (1–3). Since that time approximately 400 cases have been reported, with an estimated incidence of 1/365,520 hospital admissions (2,4 – 6). Of these, only 10 were identified preoperatively (3,7). The incidence appears to be increasing, possibly due to increased life expectancies (7,8). Although it has been reported in patients aged 2 to 100 years, the average age of incidence for gallbladder volvulus is 65–75 years. There is a 3:1 female to male sex predilection, and 84% of patients are elderly women (2,9 –13).
Etiology and Pathophysiology Gallbladder torsion is believed to occur in anatomically predisposed patients as a result of a precipitating event. It is estimated that 4% to 5% of the population is affected by an anatomic variant that could lead to gallbladder volvulus (1). Four such anatomic variants are have been identified (2,4,5,8,10,14). In the first variant, abnormal migration of the pars cystica from the hepatic diverticulum during the 4th–7th weeks of embryological development results in an absence of a gallbladder mesentery. This creates a free-floating gallbladder suspended only by the cystic duct and artery. In the second anomaly, the normally formed mesentery in an elderly patient relaxes and elongates, becoming progressively mobile. Atrophy of the liver combined with decreasing elasticity of connective tissues leads to viceroptosis, allowing torsion of
Clinical Presentation The clinical presentation of gallbladder torsion may be due either to recurrent episodes of incomplete (⬍ 180 degree) volvulus, or due to a single complete (⬎ 180 degree) volvulus of the organ (2,12). The former presents as recurrent episodes of slowly progressive pain, with variably associated nausea and vomiting. In the latter, there is an abrupt onset of severe right upper quadrant pain, early onset of nausea and vomiting, and frequently there is a palpable abdominal mass (2,8,9,12,14,16,17). Some authors have observed a clinical triad in gallbladder torsion that consists of a pulse-temperature discrepancy, a palpable right upper quadrant mass, and a lack of toxicity and jaundice (2). A mass is palpable in 20% to 30% of cases, and 20% to 50% have gallstones, in contrast to 90% with stones in typical acute cholecystitis (8,9,18). Fever and leukocytosis are inconsistently present, and it has been observed that a lower frequency of fever, leukocytosis, and jaundice, accompanied by a poor response to antibiotics, distinguishes gallbladder torsion from the usual case of acute cholecystitis (6,7,9). A preoperative diagnosis of acute gallbladder torsion is present in only 10% of cases, with the majority of cases diagnosed intraoperatively (9,10,16,18). The rate of accurate preoperative diagnosis may be expected to increase due to ever more widely available abdominal ultrasound and computed tomography (11,12,14,19).
Laboratory Evaluation There is no single reliable preoperative test for gallbladder torsion (16). The white blood cell (WBC) count is usually normal at the onset of symptoms but rises as gallbladder ischemia develops (2,8). A hypochloremic, hypokalemic metabolic alkalosis may be present (20). Liver function tests are usually normal because the com-
400
mon bile duct and the hepatic ducts are not involved in gallbladder torsion, and jaundice is present less often than in typical cholecystitis (2,9,20). Preoperative imaging studies include plain films, ultrasound, color flow Doppler, endoscopic retrograde cholangiography (ERC), CT scanning, hepatoiminodoacetic acid scanning (HIDA), and magnetic resonance cholangiopancreatography (MRCP) (2,9). Plain films are considered nonspecific and insensitive in the diagnosis of gallbladder torsion (2). Ultrasound has been the most reliable of the available imaging modalities and may show a floating gallbladder with a conical or square appearance, without gallstones, with a thickened wall, and with discontinuity of the lumen to suggest volvulus [(2,8,9,13,14,17)]. A less frequent but more specific finding is a free-floating gallbladder that is not present in the liver bed (6,8). The gallbladder wall may show “thumbprinting,” which is a sign of gangrene. A notched appearance of the outer contour of the gallbladder on ultrasound has been described in torsion, as has a stretched gallbladder pedicle seen as a conical structure comprised of multiple linear echoes that converge at the tip of the cone (6,14,15). A distended gallbladder with a thickened wall and surrounded by pericholecystic fluid is common both to torsion and to common acute cholecystitis. The degree of gallbladder distension on sonogram in torsion is greater than that seen in acute cholecystitis. This is because of the chronically scarred and thus less elastic gallbladder wall due to previous inflammation in the latter condition (8). A continuous hypoechoic line in the wall of the gallbladder on ultrasound has been described and is felt to reflect a combination of venous and lymphatic stasis (5). Ninety percent of torsioned gallbladders will show edema of the wall on ultrasound or CT scan (5,9). Color flow Doppler has been found to distinguish torsion from acute cholecystitis, based upon the presence or absence of cystic artery flow (9). Hepatobiliary scanning in acute gallbladder torsion may reveal a “bull’s-eye” image, with a focal accumulation of radioactivity medial to the photopenic area that represents the nonfilling gallbladder. Also on HIDA scanning, a fusiform common bile duct has been described, as well as delayed filling of the organ that sometimes can be seen on decubitus images (2,9). None of the sonographic or nuclear scann findings suggestive of torsion was present in the patient presented. The ERC in gallbladder torsion shows a peak-shaped cystic duct originating from a normal or slightly tented common bile duct, with non-filling of the gallbladder and discontinuity from the cystic duct (9,10). A typical appearance on ERC of crossing mucosal folds has been described, and therapeutic detorsion of the gallbladder by ERC has been accomplished (8,14). MRCP may show V-shaped tenting of the extrahepatic bile ducts due to traction by the cystic duct, with
D. M. Lemonick et al.
tapering and discontinuity of the cystic duct, and differences in signal intensity from the gallbladder, cystic duct, and extrahepatic bile ducts (2). MR imaging with fat suppressed T1-weighted imaging has been useful in showing coagulation necrosis of the gallbladder wall in volvulus, and is an unusual finding in typical acute cholecystitis (10).
Differential Diagnosis A preoperative diagnosis of acute gallbladder torsion is rarely made (9 –12,18). In one large series the diagnosis was made preoperatively in only 10% of cases (9). It is anticipated that an increasing proportion of cases will be diagnosed preoperatively due to the wide availability of ultrasound and CT (11,12,14,19). The differential diagnosis of gallbladder volvulus includes acute cholecystitis, acute pancreatitis, perforated peptic ulcer, intestinal obstruction and, in cases of extreme visceroptosis, acute appendicitis (2,4,8,11). It has been stated that gallbladder volvulus must be considered in any elderly female with acute right lower quadrant pain (4).
Treatment and Implications in Emergency Medicine Although surgical detorsion and fixation of the gallbladder have been performed, cholecystectomy is now the accepted treatment for gallbladder volvulus. Laparoscopic techniques are particularly well suited to detorsion and cholecystectomy (1,2,7,8,11,12,14,16,18 –20). The timing of surgery in acute cholecystitis is beyond the usual scope of practice for emergency physicians, but this case raises some important issues. Although torsion of the gallbladder was not suspected preoperatively in the case presented, it could be argued that this patient was still a candidate for prompt cholecystectomy based upon two findings: the presence of acalculous cholecystitis, and the ultrasound results. Prompt cholecystectomy is generally recommended for patients at high risk for gangrene and perforation. These are patients with: 1) evidence of systemic toxicity (temperatures higher than 39° C or 102.2° F, a pulse rate of ⬎ 120 beats/min, and a left shift in the white blood cell count ⬎ 90% polymorphonuclear leukocytes, 2) emphysematous cholecystitis, and 3) acalculous cholecystitis (21). The latter group usually occurs in critically ill trauma and postoperative patients, especially 2 to 4 weeks after injury. The acute cholecystitis in the patient presented was acalculous, and thus should have indicated prompt surgery. Patients identified as being at high risk for gallbladder gangrene or perforation are treated with appropriate an-
Gallbladder Torsion
tibiotics (gentamycin and ampicillin, or single agents such as piperacillin, ceftriaxone, or a quinolone), and then undergo either urgent cholecystectomy or, if the surgical risk is prohibitive, percutaneous transhepatic cholecystostomy (21). Prompt cholecystectomy in this patient was also indicated by the sonogram findings. A risk score for gallbladder perforation has been devised based upon the preoperative ultrasound findings (22). Pericholecystic fluid is assigned 7 points; distention of the gallbladder, 4 points; intraluminal membrane, 4 points; round gallbladder, 3 points; intrauminal debris, 3 points; sonolucent zone in the gallbladder wall, 2 points; and a thick gallbladder wall (⬎ 3.5 mm), 1 point. A score of 12 or more points requires urgent cholecystectomy. The patient presented had pericholecystic fluid, a distended gallbladder, and a thickened gallbladder wall, for a score of 12 points, indicating the need for prompt surgical therapy.
Prognosis Factors associated with increased morbidity and mortality from torsion of the gallbladder include increased age, the presence of co-morbidities, delayed or missed diagnosis, development of gangrene, perforation, biliary peritonitis, and sepsis (1,2,8,23). In patients with complete gallbladder volvulus in whom detorsion is not accomplished, mortality approaches 100% (24). Early diagnosis and treatment of gallbladder torsion prevents gangrene and perforation, and has resulted in mortality as low as 3% to 5% (1,2,4,8,10,24 –26).
Conclusion Gallbladder torsion is a rare cause of acute cholecystitis that is seen primarily in elderly women. It results from anatomic anomalies combined with precipitating factors that predispose the gallbladder to twisting and ischemia. Without prompt diagnosis and treatment, the gallbladder becomes gangrenous and may perforate. Consideration of this rare diagnosis early in the course of acute rightsided abdominal pain and recognition of its characteristic ultrasound, nuclear scan, and CT scan findings can hasten cholecystectomy. The possibility of gallbladder torsion as a cause of acute abdominal pain reminds the emergency physician to be vigilant for those patients at highest risk for gallbladder gangrene and perforation. Thus, an acceptably low surgical morbidity and mortality can be achieved. Laparoscopic cholecystectomy is well suited to the unusual anatomy in gallbladder volvulus, and has become the preferred surgical approach to this rare emergent condition.
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REFERENCES 1. Nicholas JM. Image of the month: gallbladder volvulus. Arch Surg 2002;137:741–2. 2. Saber AA, Rosenthal RJ, Brasesco OE, et al. Gallbladder volvulus. 2002. Available at: www.emedicine.com. Accessed November 1, 2004. 3. Hendrickson RJ, Ognibene SJ, Hirokowa TI. Extra-anatomic gallbladder torsion. Am J Surg 2003;185:288. 4. Ortiz-Gonzales J, Reyes-Segura MP, Gutierrez-Carrillo F, et al. Volvulus of the gallbladder. Dig Dis Sci 2003;48:1116 –7. 5. Cameron EW, Beale TJ, Pearson RH. Case report: torsion of the gallbladder on ultrasound— differentiation from acalculous cholecystitis. Clin Radiol 1993;47:285– 6. 6. Yeh H-C, Weiss MF, Gerson CD. Torsion of the gallbladder: the ultrasonographic features. J Clin Ultrasound 1989;17:123–5. 7. Marano A, Yahchouchy-Chouillard E, Spinelli R, et al. Gallbladder torsion: report of four cases and review of the literature. Asian J Surg 2002;25:175– 8. 8. Vosswinkel JA, Colantonio AL. Torsion of the gallbladder: laparoscopic identification and treatment. Surg Endosc 1999;13: 1154 – 6. 9. Nakao A, Matsuda T, Funabiki S, et al. Gallbladder torsion: case report and review of 245 cases reported in the Japanese literature. J Hepatobiliary Pancreat Surg 1999;6:418 –21. 10. Aibe H, Honda H, Kuroiwa T, et al. Gallbladder torsion: case report. Abdom Imaging 2002;27:51–3. 11. Desmaizieres FC, Montemagno S, de Lavernette XB, et al. Torsion of the gallbladder in an adult: a rare case of acute cholecystitis. Int Surg 2002;87:87–9. 12. Rajagopal R, Rajagopal A. Acute torsion of the gallbladder. Am J Surg 2001;182:534 –5. 13. Hinoshita E, Nishizaki T, Wakasugi K, et al. Preoperative imaging can diagnose torsion of the gallbladder: report of a case. Hepatogastroenterology 1999;46:2212–5. 14. Aharoni D, Hadas-Halpern I, Fisher D, et al. Torsion of the fundus of gallbladder demonstrated on ultrasound and treated with ERCP. Abdom Imaging 2000;25:269 –71. 15. Iannelli A, Marano A, Fabiani P, et al. Minerva Chir Gallbladder torsion. A case report. 2003;58:393– 4. 16. Jarman B, Price PD, Holden C. Acute gallbladder torsion: a review and case studies. Contemp Surg 2003;59:174 – 6. 17. Quinn SF, Fazzio F, Jones E. Torsion of the gallbladder: findings on CT and sonography and role of percutaneous cholecystectomy. AJR Am J Roentgenol 1987;148:881–2. 18. Chui AKK. Commentary: gallbladder torsion. Asian J Surg 2002; 25:179. 19. Lim KT, Casey RG, Ryan JF, et al. Torsion of the gallbladder. Ir J Med Sci 2002;171:56 –9. 20. Kleiss K, Choy-Hee L, Fogle R, et al. Torsion of the gallbladder in pregnancy. A case report. J Reprod Med 2003;48:206 – 8. 21. Barkun JS, Lewis RT. Infections in the upper abdomen: biliary tract, pancreas, liver, and spleen. In: Wilmore DW, Cheung LY, Harken AH, Holcroft JW, Meakins JL, Soper NJ, eds. ACS surgery: principles and practice. New York: WebMD Corporation; 2001:1267–9. 22. Miyazaki K, Uchiyama A, Nakayama F. New approach to the timing of operative intervention for acute cholecystitis: use of ultrasound risk score (abstr). The 32nd World Congress of Surgery. Sydney, Australia: September 20 –26, 1987. 23. Whipple RD, Sabo RR. Acute torsion of the gallbladder. Am J Surg 1979;137:798 –9. 24. Losken A, Wilson BW, Sherman R. Torsion of the gallbladder: a case report and review of the literature. Am Surg 1997;63:975– 8. 25. Lal RB, Pepper M, Puestow CB. Torsion of the gallbladder. Arch Surg 1968;97:750 –2. 26. Butsch JL, Luchette F. Torsion of the gallbladder. Arch Surg 1985;120:1323.