Interesting anatomical anomaly predisposing to gallbladder torsion

Abstract

A 72-year-old female presents with sudden onset, severe, colicky, epigastric pain for 12 h following consumption of dinner. Associated nausea without vomiting was noted. No similar previous episodes are recalled. Past medical history included Parkinson's disease, hypothyroidism and hypertension. Regular medications included levodopa/carbidopa, thyroxine, aspirin and antihypertensives. She reports no past surgical history.On examination, she was afebrile and vital signs were normal. Her abdomen soft, but tender in the right hypochondrium, with positive Murphy's sign. No signs of peritonitis were elicited.Laboratory evaluations showed mild leucocytosis (11 × 10 9 /L) and elevated C-reactive protein (120). Other biochemical markers including liver function tests, lipase and troponins were normal. Biliary tract ultrasound revealed signs of cholecystitis, but no evidence of cholelithiasis (Fig. 1). The common bile duct meas-

Gall bladder torsion: a disease of the elderly

“…The atrophy of adipose and local tissue that occurs in the elderly encourages free suspension of the gall bladder, which increases its susceptibility for rotational instability 6. Other risk factors include: visceroptosis, intense stomach and bowel peristalsis, malnutrition, blunt trauma and a tortuous atherosclerotic cystic artery 7 8. Some authors also implicate kyphoscoliosis as a risk factor, which can act as a fulcrum for torsion.…”

“…Some authors also implicate kyphoscoliosis as a risk factor, which can act as a fulcrum for torsion. The role of cholelithiasis is controversial, with approximately 20%–33% of patients with torsion having gallstones 1 7–9…”

“…There have been several signs reported with the use of CT imaging, including: an enlarged gall bladder outside of the gall bladder fossa, severe pericholecystic fluid, prominent cystic artery to the right of the gall bladder and v-shaped distortion of extrahepatic ducts or a ‘Whirl sign’ with twisting of cystic artery 1 11–13. Nuclear medicine scans with use of hydroxyiminodiacetic acid have been reported to demonstrate more specific findings, such as a ‘bulls-eye’ sign, due to accumulated radioisotope 7. Alternatively, MRI has been reported to reveal the twisted cystic duct and may therefore provide the most specificity in preoperative diagnostics 7 14.…”

“…Nuclear medicine scans with use of hydroxyiminodiacetic acid have been reported to demonstrate more specific findings, such as a ‘bulls-eye’ sign, due to accumulated radioisotope 7. Alternatively, MRI has been reported to reveal the twisted cystic duct and may therefore provide the most specificity in preoperative diagnostics 7 14. Despite these advancements in imaging technology, there has been no improvement in the reported preoperative diagnosis rates 5.…”

“…Despite these advancements in imaging technology, there has been no improvement in the reported preoperative diagnosis rates 5. The gall bladder rotates on its mesentery in the axis of the cystic duct and artery, causing necrosis secondary to biliary and arterial obstruction 7. The authors implicate intense peristalsis of the stomach and duodenum with clockwise rotation, and the transverse colon with counterclockwise rotation.…”