Torsion of the gallbladder: a rare but important differential to consider when treating acute cholecystitis non-operatively

Abstract

A 79-year-old woman presented with postprandial epigastric pain. She had normal vital signs, inflammatory markers and liver function tests. Ultrasound and CT of the abdomen demonstrated features consistent with acute cholecystitis. Her medical comorbidities and extensive abdominal surgical history prompted the decision to treat non-operatively. Despite optimal medical management, worsening abdominal pain and uptrending inflammatory markers developed. She underwent an emergency laparoscopy which revealed a necrotic gallbladder secondary to an anticlockwise complete gallbladder torsion; a rare condition associated with significant morbidity and mortality if managed non-operatively. Laparoscopic cholecystectomy was achieved without complication and the patient had an uneventful recovery. Preoperative diagnosis of torsion of the gallbladder is difficult. However, there are certain patient demographics and imaging characteristics that can help surgeons differentiate it from acute cholecystitis; a condition which can be safely managed non-operatively in selected patients. The differentiating features are elaborated on in this case report.

Gallbladder Torsion: A Rare but Critical Diagnosis

“… 8 Ultrasound and CT may also demonstrate abnormal positioning of the gallbladder, such as with a transverse orientation or a twisted vascular pedicle or cystic duct to the right of the distended gallbladder. 4 The presented case demonstrated transverse orientation of the gallbladder with the fundus directed towards the left hemiabdomen as opposed to the right. Additionally, there was an enhancing vascular pedicle and/or cystic duct along the right margin of the gallbladder.…”

“…3 Imaging may aid in the pre-operative diagnosis of gallbladder torsion, though imaging findings overlap with non-torsion causes of acute cholecystitis, such as gallbladder distention, wall thickening, and pericholecystic fluid. 4 The prevalence of gallstones in gallbladder torsion is significantly less than those with acute gallbladder pathology without torsion. 8 Ultrasound and CT may also demonstrate abnormal positioning of the gallbladder, such as with a transverse orientation or a twisted vascular pedicle or cystic duct to the right of the distended gallbladder.…”

“…1 Pre-operative diagnosis is difficult though important as conservative treatments often pursued in cases of nontorsion-related acute cholecystitis in the elderly may delay surgical intervention and predispose to gallbladder necrosis, perforation, and sepsis. 1,[3][4][5] Torsion of the gallbladder results in obstruction of biliary outflow from the gallbladder and narrowing or occlusion of the cystic artery perfusing the gallbladder. 3 Although the direct cause of gallbladder torsion is unknown, it is thought that congenitally abnormal, incomplete, or absent mesenteric attachments of the gallbladder to the gallbladder fossa of the liver, sometimes termed floating gallbladder or wandering gallbladder, may predispose to torsion.…”

“…1 Non-torsion related acute cholecystitis may be treated conservatively with antibiotics or percutaneous drainage, however, a delay in diagnosis or misdiagnosis of gallbladder torsion may lead to gallbladder necrosis and subsequent perforation, biliary peritonitis, and sepsis. [3][4][5] Improving the rate of pre-operative diagnosis of gallbladder torsion is essential to reduce its associated morbidity and mortality.…”

A Detached Gallbladder Situated Below the Transverse Colon: A Case Report of an Unusual Position

“…Certain individuals may encounter persistent stomach pain or discomfort, although others may exhibit no symptoms. In instances of increased severity, the condition of a mobile gallbladder can lead to torsion and necrosis of the organ due to the twisting and subsequent obstruction of the cystic artery and duct [7][8][9][10].…”