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Introduction
Acalculous cholecystitis accounts for 2%–15% of acute
cholecystitis cases and is diagnosed as gallbladder inflam-
mation without evidence of gallstone cystic duct obstruc-
tion.1 Gallbladder torsion (GT) is a rare cause of acalculous
cholecystitis which was first diagnosed in 1898,2 with
approximately 500 cases reported since3 and an incidence of
0.1% in patients with acute cholecystitis.4 GT occurs more
commonly in elderly females and is associated with increased
morbidity and mortality if diagnosis is delayed.3 Here, we
report a case of an elderly female patient who was success-
fully treated for acute necrotising acalculous cholecystitis as
a result of GT.
Case presentation
A 89-year-old woman presented with sudden onset of severe
epigastric pain, radiating across her right costal margin
towards her back. The pain was associated with nausea but
no vomiting, bowels had opened the day before, no associa-
tion with food and no other symptoms. The patient had a
background medical history of a previous upper gastrointes-
tinal bleed, gastro-oesophageal reflux disease, hiatus hernia,
chronic constipation, hypertension and emphysema. She was
a non-smoker and non-drinker.
Physical examination revealed a mildly distended, soft
abdomen with normal bowel sounds, marked epigastric
tenderness and palpable mass in epigastrium; Murphy’s
negative. Vital signs were within normal limits and she was
afebrile. Blood biochemistry was essentially normal: bili-
rubin 5 µmol/L, alkaline phosphatase (ALP) 41 U/L,
gamma-glutamyl transferase (GGT) 31 U/L, alanine
transaminase (ALT) 15 U/L, aspartate transaminase (AST)
20 U/L, C-reactive protein (CRP) 2 mg/L, white cell count
(WCC) 11 × 109/L and lipase 18 U/L. Computed tomogra-
phy (CT) imaging revealed significant acute cholecystitis,
associated with a moderately dilated gallbladder (4.5 cm
diameter), thickened gallbladder wall, pericholecystic free
fluid and fat stranding (Figure 1). An upper abdominal
Rare case report of acalculous cholecystitis:
Gallbladder torsion resulting in rupture
Brielle Elizabeth Wood1, Jodie Trautman2, Nicholas Smith2
and Soni Putnis2
Abstract
Acalculous cholecystitis caused by gallbladder torsion is a rare condition. Only 500 cases have been reported since the first
diagnosed case in 1898. We present the case of a 89-year-old woman with sudden onset of severe epigastric pain, radiating
across her right costal margin, associated with nausea. Her abdomen was soft, mildly distended, Murphy’s negative but with
epigastric tenderness and palpable mass. Computed tomography and ultrasound demonstrated significant acute cholecystitis,
with the common bile duct measuring 7 mm. Due to the patients’ comorbidities, conservative treatment was initiated, until
she was becoming increasing worse, so a laparoscopic cholecystectomy was performed. The operation revealed gallbladder
torsion causing complete gallbladder necrosis and perforation with intraperitoneal biliary spillage. Gallbladder torsion should
be a high differential if an elderly female patient presenting with sudden onset of abdominal pain, tender epigastric/right upper
quadrant mass and a distended gallbladder on imaging. A laparoscopic cholecystectomy must be performed promptly to
reduce the likelihood of gallbladder rupture and reduce the mortality and morbidity associated with this condition.
Keywords
Gallbladder torsion, cholecystectomy, gallbladder rupture, acalculous cholecystitis, rare diseases
Date received: 8 July 2018; accepted: 13 December 2018
1Department of Surgery, Robina Hospital, Robina, QLD, Australia
2 Department of Surgery, Wollongong Hospital, Wollongong, NSW,
Australia
Corresponding Author:
Brielle Elizabeth Wood, Department of Surgery, Robina Hospital, Locked
Bag 15, Robina, QLD 4226, Australia.
Email: brielle.e.wood@gmail.com
823385SCO0010.1177/2050313X18823385SAGE Open Medical Case ReportsWood etal.
case-report2019
Case Report
2 SAGE Open Medical Case Reports
ultrasound done the following day revealed acute acalcu-
lous cholecystitis with the common bile duct measuring
7 mm in diameter, no intrahepatic duct dilatation and did
not report on blood flow.
Her ASA-PS (American Society of Anesthesiologist
Physical Status) score was III and CCI (Charlson comor-
bidity index) score was 5, which made her a high-risk sur-
gical candidate. Therefore, she was initially treated
conservatively as acute cholecystitis with intravenous
antibiotics, until day two post-admission she become
increasingly unwell and underwent a laparoscopic chole-
cystectomy. Operative findings were of a pedicled, supra-
hepatic gallbladder on a narrow cystic duct stalk which
appeared acutely torted with consequent complete gall-
bladder necrosis and perforation (Figure 2). Intraoperative
cholangiogram demonstrated normal biliary anatomy,
long cystic duct and nil dilation or filing defects.
Histopathology showed features of acute necrotising
cholecystitis, without gallstones, a large amount of haem-
orrhagic fluid in lumen and two areas of stricture in the
region of the gallbladder neck (19 and 34 mm from cystic
duct margin). The patient was discharged 5 days after the
operation.
Discussion
GT is a rare and potentially life-threatening condition if not
promptly diagnosed and treated. Since GT was first diag-
nosed in 1898,2 approximately 500 cases have been reported3
and occurs at a rate of 0.1% in patients diagnosed with acute
cholecystitis.4 GT is a result of the gallbladder becoming
pedunculated, with its only attachment to the liver by the
cystic mesentery; this phenomenon is referred to as ‘floating
gallbladder’.2
Figure 1. Computed tomography image demonstrating
significant acute cholecystitis, associated with a dilated and
thickened wall gallbladder plus pericholecystic free fluid and fat
stranding.
Figure 2. Intraoperative photo demonstrating gallbladder (GB) torsion and associated GB necrosis. Note position of GB situated upon
the diaphragmatic hepatic surface instead of within the GB fossa. Also note the thin and suspended GB pedicle which contained both the
cystic duct and artery, and which was the axis of torsion, thus producing resultant GB ischaemia.
Wood etal. 3
The gallbladder can rotate either clockwise or anticlock-
wise. The most common direction for torsion is clockwise and
is thought to be related to gastric (clockwise) or colonic (coun-
terclockwise) peristalsis.5 The degree of torsion determines the
severity of GT. Type I is less than 180 degrees, allowing limited
blood supply, and type II is more than 180 degrees, causing
complete obstruction.6 The gallbladder can undergo infarction,
gangrene and/or perforation, when blood supply is affected.
Case studies over the years have reported numerous risk
factors, signs, symptoms and investigations to help diagnose
GT. Elderly patients are at greater risk of the gallbladder
becoming separated from the liver, due to loss of visceral fat
and elasticity with increasing age.7 Clinical findings indica-
tive of GT include sudden onset of abdominal pain, early
emesis and tender mass in the right upper quadrant.8 When
comparing the biochemistry of acute cholecystitis and GT,
GT often has normal liver function and biliary enzyme but
elevated inflammatory markers.9 Preoperative imaging usu-
ally involves a CT scan demonstrating a distended gallblad-
der, with high attenuation and a circular structure to the right
of the gallbladder.10 GT can theoretically be ruled out if a
Doppler ultrasonography shows normal blood flow.11 A more
reliable diagnostic test is a magnetic resonance cholangio-
pancreatography (MRCP). The findings positive for GT
include gallbladder fundus towards the abdominal centre,
V-shaped extrahepatic duct and cystic duct torsion.5,9
Although we are aware of the above points of diagnosis, the
pre-operative diagnosis of GT is not commonly achieved and
is not diagnosed until a cholecystectomy is performed.
This case report demonstrates the importance of keeping the
differential diagnosis of a GT at the top of the list in an elderly
female with acalculous cholecystitis. In hindsight she had clini-
cal and radiological signs suggestive of GT, which could have
lead us to perform an MRCP for a prompter diagnosis. Early
diagnosis or suspicion of GT can lead to a more rapid definitive
treatment (cholecystectomy) and reduce the risk of the poten-
tially fatal sequel of gallbladder necrosis and perforation.
Conclusion
When a patient suffers from sudden onset of abdominal pain,
a tender epigastric mass and a distended gallbladder on
imaging, the differential diagnosis of GT must be kept in
mind to reduce morbidity and mortality. A laparoscopic chol-
ecystectomy must be performed promptly to reduce the like-
lihood of gallbladder rupture.
Acknowledgements
N.S. and S.P. oversaw the diagnosis and clinical care provided to
the patient. B.E.W., J.T. and N.S. performed the literature review
and wrote the manuscript. All authors read, edited and approved the
final manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship and/or publication of this article.
Ethical approval
Our institution does not require ethical approval for reporting indi-
vidual cases or case series.
Funding
The author(s) received no financial support for the research, author-
ship and/or publication of this article.
Informed consent
Informed consent was obtained from the patient for the publication
of this case report and accompanying images.
ORCID iD
Brielle Elizabeth Wood https://orcid.org/0000-0001-5854-4818
References
1. Treinen C, Lomelin D, Krause C, et al. Acute acalculous chol-
ecystitis in the critically ill: risk factors and surgical strategies.
Langenbecks Arch Surg 2015; 400(4): 421–427.
2. Wendel AV.VI. A case of floating gall-bladder and kidney
complicated by cholelithiasis, with perforation of the gall-
bladder. Ann Surg 1898; 27(2): 199–202.
3. Reilly DJ, Kalogeropoulos G and Thiruchelvam D. Torsion
of the gallbladder: a systematic review. HPB 2012; 14(10):
669–672.
4. Beliaev AM, Shapkov P and Booth M. Incidence of gallblad-
der torsion in acute cholecystectomy patients. ANZ J Surg
2015; 85(10): 793.
5. Garciavilla PC, Alvarez JF and Uzqueda GV. Diagnosis and
laparoscopic approach to gallbladder torsion and cholelithi-
asis. JSLS 2010; 14(1): 147–151.
6. Gross RE. Congenital anomalies of the gallbladder. Arch Surg
1936; 32: 131–162.
7. Matsuhashi N, Satake S, Yawata K, et al. Volvulus of the
gall bladder diagnosed by ultrasonography, computed tomog-
raphy, coronal magnetic resonance imaging and magnetic
resonance cholangio-pancreatography. World J Gastroenterol
2006; 12(28): 4599–4601.
8. Lau WY, Fan ST and Wong SH. Acute torsion of the gall blad-
der in the aged: a re-emphasis on clinical diagnosis. Aust N Z
J Surg 1982; 52(5): 492–494.
9. Izuishi K, Kiuchi T and Mori H. Education and imaging.
Hepatobiliary and pancreatic: gallbladder torsion diagnosed
by curved multi-planar reconstruction computed tomography.
J Gastroenterol Hepatol 2014; 29(4): 665.
10. Merine D, Meziane M and Fishman EK. CT diagnosis of
gallbladder torsion. J Comput Assist Tomogr 1987; 11(4):
712–713.
11. Lee SE, Choi YS and Kim BJ. Torsion of the gallbladder in
pregnancy. J Korean Surg Soc 2013; 85(6): 302–304.
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