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The "floating gallbladder." Ultrasound image in Patient 2 of a markedly enlarged gallbladder with a multi-layered hypoechoic rim demonstrating an edematous wall without calculi - the so-called classic description
Source publication
Acute gallbladder volvulus continues to remain a relatively uncommon process, manifesting itself usually during exploration for an acute surgical abdomen with a presumptive diagnosis of acute cholecystitis. The pathophysiology is that of mechanical organo-axial torsion along the gallbladder's longitudinal axis involving the cystic duct and cystic a...
Similar publications
Gallbladder volvulus is a rare entity. The condition results in rotation of the gallbladder on its mesentery along the axis of cystic duct and artery. Gallbladder volvulus is a condition in which the organ twists on its long axis to the point where its vascular supply is compromised. Gallbladder volvulus is a rare entity which mostly occurs in elde...
Citations
... While the main etiology is undetermined, it has been reported it originates from lack of adhesion of the gallbladder to the liver ("floating gallbladder") which result in twisting around the cystic bile duct [3]. This pathological process commonly mimics acute cholecystitis and delay the diagnosis of the volvulus ending with gangrenous and perforation of the gallbladder [4]. The prevalence of gallbladder volvulus has been primarily noted in elderly patients with few reports from pediatrics age group [3,5]. ...
Introduction
Gallbladder volvulus is the rarest form of gall bladder pathology and it is also rare cause of acute abdomen. The exact etiology of gallbladder volvulus is undetermined and mostly mimics acute cholecystitis which delays diagnosis and management of patients.
Case presentation
In this case report we present 7 years old male child who underwent exploratory laparotomy and intraoperative findings of 360 degree twisted, frankly gangrenous, and perforated at the fundus of the gallbladder. Cholecystectomy was done and the patient had smooth post-operative course and discharged improved.
Clinical discussion
Gallbladder volvulus is a rare cause of acute abdomen especially in pediatric population and it mostly mimics acute acalculous cholecystitis leading to delayed diagnosis and increased risk of complications such as gallbladder gangrene, perforation, bile peritonitis, morbidity and mortality.
Conclusion
Even though gallbladder volvulus is rare as cause of acute abdomen, one has to consider in the differential diagnosis as high index of suspicion is important for early diagnosis and management.
... To date, the etiology of gallbladder torsion remains unclear. Variations in physiology and anatomy may cause the gallbladder to "float" freely in its original position, such as an abnormal mesentery with overly long or abnormal fixation of the gallbladder and liver (5). The gallbladder is allowed to hang or "float" because of decreased visceral fat, hepatic atrophy, and increased elasticity of the gallbladder, which is seen as more common in the elderly. ...
... Severe gastrointestinal peristalsis near the gallbladder and mechanical susceptibility due to kyphosis scoliosis have been considered as predisposing triggers for gallbladder torsion (6). Only a quarter to a half of patients with gallbladder torsion have gallstones, so gallstones are a concomitant condition and not likely to be the underlying etiology (1,5). According to the gross classification, gallbladder torsion can be divided into 2 classifications: one is that the gallbladder and cystic duct are suspended to the liver through the mesentery, while the other is that the cystic duct is connected to the liver alone (7,8). ...
... Hepatobiliary immoderately acid (HIDA) scans theoretically show the "bulls-eye" feature of gallbladder torsion. This shows that the cystic duct is not optically filled, indicating that it is blocked (5,14). When patients have 2 triad signs in clinical symptoms and physical examination, and patients have a poor response to antibiotics, gallbladder torsion should be regarded as one of the differential diagnoses of acute calculous cholecystitis (11). ...
Background:
Gallbladder torsion is very rare and easily misdiagnosed as biliary disease. It is defined as the rotation of the gallbladder along the axis of the cystic pedicle on the mesentery. As gallbladder rotation involves the gallbladder artery, the blood supply is blocked, resulting in gallbladder ischemia and eventual necrosis. If misdiagnosis occurs and treatment is delayed, gallbladder torsion can develop into a lethal disease. The typical imaging features of gallbladder torsion in this case are a good learning resource for our young physicians, as well as providing a rare, unusual and typical case for our current literature database.
Case description:
We present a rare case of gallbladder torsion in a 19-year-old man. The patient complained of sudden recurrent pain and discomfort in the right upper abdomen with vomiting for 12 hours. Abdominal ultrasound and computed tomography (CT) scan showed gallbladder enlargement and signs of acute cholecystitis in emergency examination, and there were no signs of cholecystolithiasis. Considering that the patient was a young male and the patients prefer conservative treatment, symptomatic treatment was given. However, there was no obvious effect after 1 day of medical treatment, but severe abdominal pain in the upper right quadrant continues to progress. Finally, the patient underwent laparoscopic cholecystectomy, and the gallbladder was found to be enlarged with ischemic necrosis, which was caused by gallbladder torsion. The patient recovered 2 days after surgery and was discharged without complications.
Conclusions:
Although the clinical manifestation is similar to that of typical acute calculous cholecystitis, gallbladder torsion can be diagnosed early through some special signs on imaging examination, such as distorted cystic duct signs ("beak and whirl" sign), gallbladder dilatation with gallbladder fossa effusion, and gallbladder in the horizontal position. These signs can help primary surgical treatment and prevent fatal complications such as gallbladder gangrene, perforation, and biliary peritonitis. Therefore, for inexperienced doctors, careful imaging features are required for the correct diagnosis of rare gallbladder torsion.
Keywords:
Gallbladder torsion; acute abdominal disease; cholecystitis; case report.
... Majoritatea autorilor descriu că litiaza vezicii biliare este detectată în 1/3 de cazuri, însă cu siguranță nu contribuie la dezvoltare TVB [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]22]. De asemenea sunt descrise cazuri de hernierea vezicii biliare torsionate în hernia parastomală [30], foramenul lui Winslow [31] și Spigel [32]. ...
... Predominantly seen in women (1:3 male-to-female ratio), 85% of the cases occur in patients aged 60 to 80 years [7,14]. Rarely, children as young as two years may be affected [15]. ...
... Lau et al. in 1982 described the "Triad of Triads" to help identify the features of GB volvulus [17,18]. Even with advances in radiological diagnosis, only five cases of GB volvulus have been diagnosed preoperatively to date [13][14][15]. Emergency detorsion and cholecystectomy (laparoscopic or open) is the treatment of choice. Delay in treatment can lead to biliary peritonitis from GB rupture and sequelae [19]. ...
A middle-aged woman with uterine fibroids presented with menorrhagia and diffuse abdominal pain. The patient was anemic, afebrile, anicteric, and had a palpable tender gall bladder. Initial whole abdomen ultrasonography was inconclusive, and computed tomography of her abdomen revealed partial volvulus of the gall bladder. Following optimization, the patient had undergone open cholecystectomy under general anesthesia. Intraoperatively, the gall bladder was distended, with edematous walls and rotated clockwise (270°) along the long axis to the cystic duct. We noted no gangrenous changes, and we performed detorsion of the gall bladder and cholecystectomy. Volvulus of the gall bladder can be associated with high mortality and morbidity. Good clinical examination, a high degree of suspicion given the presentation of the case, proper investigation, and timely management prevented poor outcomes in our case.
... Acute gallbladder torsion remains a relatively uncommon process, usually diagnosed intraoperatively with or without the presumptive diagnosis of acute cholecystitis. 1 Gallbladder torsion is a condition where the gallbladder twists on its long axis causing vascular compromise and as a result secondary gallbladder ischaemia or necrosis occurs. This condition has to be treated surgically, and early intervention is important, as any delay may lead to a fatal outcome. 2 According to the literature, the mortality rate of torsion of the gallbladder is 6%, and none of the deaths occurred in patients who were diagnosed preoperatively. ...
Objective
An 87-year-old attended the emergency department with sharp upper abdominal pain, radiating to back with a pain score of 10/10. On examination, severe epigastric tenderness was noted. Past surgical history: bilateral salphingo-oopherectomy. Repair for paraumblical hernia and right total hip replacement. No history of cholecystectomy. Inflammatory markers were raised. Cholecystitis/gall bladder perforation was suspected and contrast CT was performed.
Methods
CT abdomen and pelvis – in comparison to the previous CT scan which was done in 2018, where gall bladder was in the correct anatomical location, the gall bladder was not seen in the gall bladder fossa in the current study. However, a gall bladder like suspicious structure was noticed within the upper abdomen to the left of midline anterior to the gastric pylorus with significant inflammatory changes. Therefore, considering the clinical picture and CT findings, it was suggestive of acute cholecystitis with torsion of gall bladder.
Results
Patient was started on i.v. antibiotics and laparoscopic assessment was carried out on the following day. Intraoperatively, the surgeons were unable to locate the gall bladder in its normal anatomical position, but incidentally found a mass in the left upper abdomen which appeared gangrenous. This was removed and sent for histopathology. Histology report confirmed that the specimen was gall bladder with features suggestive of pre-existing chronic cholecystitis, with recent venous infarction.
Conclusion
Torsion of gall bladder is a very rare entity and if left untreated could lead to fatal sequelae of gangrene and perforation resulting in biliary peritonitis. There is evidence which suggest that torsion of gall bladder is more common in elderly females due to loss of visceral fat but the pre-operative diagnosis using imaging modalities has always been challenging. But in this particular case, the radiologist was able to make the precise diagnosis pre-operatively using the cross-sectional study of an advanced imaging modality like the CT scan with contrast which also helped the surgeons in making the decision for immediate surgery rather than planning for routine conservative management for acute cholecystitis. The importance of cross-sectional study with intravenous contrast in diagnosing unusual presentation of gall bladder related and potentially life-threatening abdominal pathology has been highlighted in this case study. It is also evident that how imaging modalities play a significant role in altering acute management plan.
... Majoritatea autorilor descriu că litiaza vezicii biliare este detectată în 1/3 de cazuri, însă cu siguranță nu contribuie la dezvoltare TVB [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16]22]. De asemenea sunt descrise cazuri de hernierea vezicii biliare torsionate în hernia parastomală [30], foramenul lui Winslow [31] și Spigel [32]. ...
... Despite improvements in diagnostic imaging modalities, majority of the cases remain undiagnosed preoperatively [1]. Torsion of the gallbladder rapidly progresses to gangrene and is linked with a very poor prognosis, even death, if not recognized and treated in time [2][3][4][5][6][7]. ...
... The etiology of the torsion always implies an anatomic abnormality that causes the gallbladder to twist [4,6,9]. Besides, a torsion-prone mesentery can develop in the elderly with loss of visceral fat, liver atrophy, and visceroptosis with the pedicle attached to the liver [3,7,8]. ...
... Despite the significant improvement in imaging modalities, the diagnosis of volvulus of the gallbladder remains difficult owing to its very low incidence and few specific symptoms. No imaging modality has proven to be sufficiently sensitive to diagnose this condition [2,4]. Distension of the gallbladder and wall thickening are almost constant, but nonspecific features are seen on both ultrasound and CT scan [1,2,[5][6][7][8][9]. ...
Torsion or volvulus of the gallbladder is a rare situation that rapidly progresses to gangrene and linked with a poor prognosis, even death, if unrecognized and untreated. An interesting and rare case of gallbladder volvulus in which diagnosis was obtained by comparing CT images and HIDA scan with SPECT-CT is presented. Relevant literature is reviewed, and recommendations are outlined.
... A triad of symptoms is early presentation, typical pain, and early vomiting, nausea. A triad of physical signs is palpable abdominal mass, absence of toxemia and jaundice, and pulse-temperature discrepancy [7,8]. In the other reported cases, he sign of "coming and going" of SHORT is inconsistent, remained pathognomonic of the volvulus of the gallbladder [4]. ...
... Gallbladder volvulus is a condition most often seen in elderly patients and has occurrence ratio between women and men of 3:1. Lipoatrophy associated with ageing, liver atrophy and the congenital presence of a long gallbladder mesentery would appear to be associated factors [2]. These factors contribute to a free-floating gallbladder that is mobile and capable of twisting at its pedicle. ...
... GV is first reported by Wendel in 1898 and dubbed the floating gallbladder [3] and there have been no more than 300 documented cases in the literature ranging from ages 2 to 100-years-old [4,5]. Clinical incidence of GV has been reported as 1:365,520 hospital admissions [2]. ...
... GV is characterised by mechanical clockwise or counter clockwise organo-axial torsion along the longitudinal axis of the gallbladder involving cystic artery and cystic duct [3]. This rotation causes ischemia and interrupts bile flow, which is responsible for clinical signs and symptoms [1]. ...
... Initial ultra sound scan revealed a picture of acalculus cholecystitis with mobile sludge in the gall bladder. She has un-ature diagnosed pre-operative imaging; the reminder found intra-operatively [3]. ...
