Torsion of the gallbladder.

Abstract

A 77-year-old woman was seen with progressive abdominal pain.
A CT scan was made and showed a large gallbladder extending into the right lower abdomen. Ultrasound was performed but demonstrated no gallstones. Laparoscopy showed a tordated, necrotic gallbladder that was attached to the liver only by the cystic artery and cystic duct. Cholecystectomy was performed.
Torsion of the gallbladder is a rare but clinically important condition in which the diagnosis seldom is made preoperatively. In radiological and clinical signs of cholecystitis without gallstones, this condition should be considered.

Full text

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GI IMAGE
Torsion of the Gallbladder
Elizabeth A. Boonstra & Boudewijn van Etten &
Ted R. Prins & Egbert Sieders & Barbara L. van Leeuwen
Received: 23 August 2011 /Accepted: 20 September 2011 /Published online: 8 October 2011
# 2011 The Author(s). This article is published with open access at Springerlink.com
Abstract
Introduction A 77-year-old woman was seen with progressive abdominal pain.
Cases A CT scan was made and showed a large gallbladder extending into the right lower abdomen. Ultrasound was
performed but demonstrated no gallstones. Laparoscopy showed a tordated, necrotic gallbladder that was attached to the
liver only by the cystic artery and cystic duct. Cholecystectomy was performed.
Conclusions Torsion of the gallbladder is a rare but clinically important condition in which the diagnosis seldom is
made preoperatively. In radiological and clinical signs of cholecystitis without gallstones, this condition should be
considered.
Keywords Gallbladder.Torsion.Cholecystitis.CT
Introduction
Torsion of the gallbladder is a rare condition and an
indication for urgent cholecystectomy. The diagnosis is
seldom made before surgery. We will present a case of
a patient with a tordated gallbladder and an overview of
the literature.
Case Report
A 77-year-old lady presented with a distended abdomen with a
constant tenderness in the right lower abdomen which
worsened with movements. There was no rebound tenderness,
defense, or palpable masses. There was no fever, nausea, or
vomiting. Her medical history included osteoporotic fractures
of T-7, T-9, and T-12, and L-1. She used pain-killers,
medication indicated for osteoporosis, and acetylsalicyclic
acid for unclear reasons. Laboratory investigation showed a
hemoglobinof7.2mmol/l(7.5–9.9),aleukocytecountof8.9×
109/l (4–10×109/l), a CRP of 50 mg/l (<5 mg/l), and a
sodium of 127 mmol/l (135–145 mmol/l). Liver tests and
bilirubin were normal. With the differential diagnosis of a
colon tumor or acute appendicitis, she was admitted to the
hospital. The next day she underwent a CTscan with oral and
intravenous contrast agents. This showed fluid collection in
the right side of the abdomen. The radiologist interpreted this
as the gallbladder with an abnormal location and configura-
tion. The appendix was normal. Around the gallbladder, there
was fat induration and induration of the right abdominal wall
(Fig. 1). For more certainty about the fluid collection, an
ultrasound investigation was performed. This revealed that
the fluid collection indeed was the gallbladder in which the
cystic duct could be followed until the common bile duct.
The gallbladder wall was thickened and layered. Gallstones
E. A. Boonstra (*):B. van Etten:B. L. van Leeuwen
Department of Abdominal Surgery,
University Medical Centre Groningen,
Hanzeplein 1,
9713 GZ Groningen, The Netherlands
e-mail: e.a.boonstra@chir.umcg.nl
T. R. Prins
Department of Radiology, University Medical Centre Groningen,
Groningen, The Netherlands
E. Sieders
Department of Hepatobiliary Surgery and Liver Transplantation,
University Medical Centre Groningen,
Groningen, The Netherlands
J Gastrointest Surg (2012) 16:882–884
DOI 10.1007/s11605-011-1712-6

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were not seen. The diagnosis of an acalculous cholecystitis
was made, and a laparoscopic cholecystectomy was consid-
ered necessary. At laparoscopy, a gangrenous and much
distended gallbladder was seen. The gallbladder was situated
at the right side of the colon and reached the right lower
quadrant of the abdomen. It was attached to the liver only by
the cysticductand artery. Therewasa 360°torsion aroundthe
cystic duct and artery (Fig. 2). Because of the location of the
gallbladder, distended bowel, and the kyphoscoliosis of the
patient, an open cholecystectomy was performed. When the
gallbladder was opened after surgery, there were no gall-
stones. The postoperative course was uncomplicated.
Histopathologic investigation of the gallbladder showed
an acute cholecystitis with hematoma and necrosis of the
gallbladder wall.
Overview of the Literature
Torsion of the gallbladder is a rare cause of cholecystitis.
The incidence is estimated at 1 in every 365.520 hospital
Fig. 1 CT image with the free-floating gallbladder
Fig. 2 The tordated cystic duct
J Gastrointest Surg (2012) 16:882–884 883

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admissions.1The first case was described by Wendel in
1898.2It is a condition mainly seen in elderly women, and
the incidence appears to increase with increased life
expectancy.3Torsion of the gallbladder can only occur in
patients with anatomic variation of gallbladder fixation to
the liver. This could be a complete, but too long and wide
mesentery or an incomplete mesentery covering only the
cystic duct and artery. In these anatomic variations, there is
a free-floating gallbladder. Another possibility is that
relaxation and atrophy of a previously normal mesentery
in the elderly cause visceroptosis.4,5For the final torsion, a
provocative moment is needed. In literature, kyphoscoliosis,
forceful peristaltic movements, adhesions, atherosclerosis of
thecysticartery,andsigmoidvolvulusarereportedaspossible
provocative factors.6Striking is that the patient in our case
report had a kyphoscoliosis. Symptoms of gallbladder
torsion are acute onset of abdominal pain, nausea, and
vomiting. These symptoms can be intermitting in case of
180° torsion.6The often unusual location of a tordated
gallbladder hampers making the right diagnosis and seldom
is the diagnosis made before surgery. There are radiological
signs that can indicate torsion of the gallbladder. Especially
the presence of the gallbladder outside the normal anatomic
fossa and a stretched cystic duct and gallbladder neck can
indicate a free-floating gallbladder and are thereby risk
factors for torsion of the gallbladder. Likewise, the absence
of bile stones in a gallbladder with signs of cholecystitis can
suggest a torsion of the gallbladder since an acalculous
cholecystitis is very rare in otherwise healthy patients. A
hypo-echogenic zone between the mucosa and serosa of the
gallbladder is a sign of venous stasis and hematoma in the
gallbladder wall.7Besides an abnormal location of the
gallbladder, a swirl sign of the cystic duct can be seen on
CT images. The gallbladder will be more distended in torsion
than in a normal acute cholecystitis.8Treatment of a tordated
gallbladder is acute (laparoscopic) cholecystectomy.
In conclusion, torsion of the gallbladder is a rare but
clinical important condition in which the diagnosis is
seldom made before surgery. At radiologic and clinical
signs of acute cholecystitis in the absence of bile stones
but with a free-floating gallbladder, this diagnosis must be
considered.
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