Gallbladder torsion resulting in gangrenous cholecystitis within a parastomal hernia: Findings on unenhanced CT

Abstract

Gallbladder torsion is a rare cause of acute gangrenous cholecystitis; its occurrence within an abdominal hernia has not been previously reported. We present such a case occurring within a parastomal hernia and imaged with unenhanced CT.

Parastomal gallbladder hernia in a septic patient

“…Most previously reported cases of parastomal gallbladder herniation had abdominal pain as the predominant presenting symptom [4] , [5] , [6] , [7] , [8] , [9] . Our patient may have had fewer localizing symptoms because of advanced age and chronic debilitation.…”

“…Furthermore, CT can assist in identifying complications of abdominal wall hernias including bowel obstruction, strangulation, and traumatic injury [12] . Most previously reported cases of parastomal gallbladder herniation included CT imaging as part of the diagnostic work-up [4] , [5] , [6] , [8] , although the gallbladder's presence in the hernia sac was identified intraoperatively in one case [9] and by abdominal radiograph in another [7] . The gallbladder may be absent from its normal anatomic location or extend from the gallbladder fossa into the parastomal hernia.…”

“…The gallbladder may be absent from its normal anatomic location or extend from the gallbladder fossa into the parastomal hernia. In this setting, CT can also aid in evaluating the gallbladder wall thickness, presence of mural or luminal gas, and presence of stones [8] .…”

“…Gallbladder herniation at any site is rare, and only a few cases have been reported in the literature [5] . Among the 6 previously reported cases of parastomal gallbladder herniation, the majority presented with progressive abdominal pain and preserved bowel function [4] , [5] , [6] , [7] , [8] , [9] . The only reported case managed without urgent cholecystectomy was treated conservatively because of patient's advanced age, cardiovascular disease, and patient preference [4] .…”

How to apply clinical cases and medical literature in the framework of a modified “failure mode and effects analysis” as a clinical reasoning tool – an illustration using the human biliary system

“…Perforation – other causes can be Epstein–Barr virus [10], liver abscess [11], blunt abdominal trauma [12], and spontaneous [13]Bile leaked into the peritoneum [9]Umbilical pain and a bluish discoloration of the skin around a known umbilical hernia presumably due to tracking of bile within the abdomen [9]Liver function test, laparotomy [9]The patient had spontaneous acalculous gallbladder perforation [9]. This condition is rare but criticalGallbladder herniation: parastomal [14–18], incisional [19–21], spontaneous ventral [22, 23], epigastric [24], transdiaphragmatic herniation [25]A midline abdominal hernia with small bowel loops, and a parastomal hernia containing the gallbladder [14]Abdominal pain [14]CT scan with oral Gastrograffin (sodium diatrizoate and meglumine diatrizoate) contrast [14]Gallbladder torsion [17]Torsion of the neck of the gallbladder with secondary suppuration leading to gangrenous changes in the gallbladder [17]Abdominal pain [17]Abdominal CT [17]Other case of gallbladder torsion [26], a new case of gallbladder torsion within an incisional hernia [27], complete gallbladder torsion [28], gallbladder torsion caused acute cholecystitis [7]A gallstone enters via the Vater papilla and later increases in size [29]Transition of a gallstone in the gastrointestinal tract leading to mechanical bowel obstruction (gallstone ileus) [29]Nausea, vomiting and abdominal pain [29]Abdominal CT, MRCP [29]Other case: gallbladder-colon fistula [30] and cholecystogastric fistula [31]Biliary-enteric fistula e.g. gallbladder-duodenal fistula [8]“Spontaneous biliary fistulas have been associated with gallbladder cancer; if they are the cause of cancer, or acomplication of it, this has not yet been defined.” [8]1-month history of episodic nausea and vomiting, and epigastric pain on admission [8]Abdominal ultrasound, CT, barium study [8]Failure of the cystic bud to develop in utero [32]Gallbladder...…”