An Uncommon Cause of Right Pain in the Hypochondrium

Abstract

Question: An 84-year-old woman presented at our hospital complaining of a sudden severe right hypochondrium pain continuing for about 1 day. She was diagnosed as having acute cholecystitis and was admitted. Her past medical history included osteoporosis and spinal canal stenosis. Her body temperature was 37.1°C, and physical examination revealed tenderness in the right hypochondrium; Murphy's sign was positive. Significant laboratory results included the following: White blood cell count, 113 × 109/L (normal, 4–11 × 109/L); aspartate aminotransferase, 50 IU/dL (normal, 7–38); lactate dehydrogenase, 288 IU/dL (normal, 106–211); and C-reactive protein, 15.4 mg/dL (normal, 0–0.5). Abdominal ultrasonography showed a distended gallbladder with a thickened wall but without gallstones. Computed tomography (CT) examination revealed an enlarged gallbladder and a twisted high-density area (Figure A, arrow). Magnetic resonance cholangiopancreatography (MRCP) also showed the same twisted, low-intensity area (Figure B, arrow). What is the diagnosis? How should the patient be managed? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. CT examination revealed an enlarged gallbladder and a twisted pedicle of the cystic duct and mesentery, the so-called whirl sign (Figure A; arrow shows the whirl sign on the CT image). MRCP showed rotation of the gallbladder even more clearly (Figure B; arrow shows the whirl sign on the MRCP image). She was diagnosed as having gallbladder torsion, and an emergency operation was performed. Because the gallbladder was necrotic and was rotated around its pedicle in a 720°clockwise manner, a cholecystectomy was performed. The patient's postoperative clinical course was uneventful and the patient was discharged from hospital on postoperative day 7. Torsion of the gallbladder is a rare abdominal emergency associated with a free-floating gallbladder. It often occurs in thin, elderly women, and the presence of gallstones is relatively uncommon (24.4%).1Nakao A. Matsuda T. Funabiki S. et al.Gallbladder torsion: case report and review of 245 cases reported in Japanese literature.J Hepatobiliary Pancreat Surg. 1999; 6: 418-421Crossref PubMed Scopus (74) Google Scholar Although the outcome is relatively good after surgery, unlike acute cholecystitis, gallbladder torsion almost never remits with conservative therapy, including the administration of antibiotics. Consequently, an accurate diagnosis is important for deciding to perform an emergency operation. The reported clinical features include a low frequency of fever and jaundice; however, the symptoms of gallbladder torsion are often similar to those of acute cholecystitis. Imaging findings, including abdominal ultrasonography, CT, and MRCP, are often the only means of diagnosing this disease. The whirl sign was first reported as a CT finding indicating midgut volvulus.2Fisher J.K. Computed tomographic diagnosis of volvulus in intestinal malrotation.Radiology. 1981; 140: 145-146Crossref PubMed Scopus (211) Google Scholar Because multidetector CT examinations are now more common, several reports have indicated that the whirl sign may also be seen in cases of gallbladder torsion.3Tajima Y. Tsuneoka N. Kuroki T. et al.Clinical images Gallbladder torsion showing a “whirl sign” on a multidetector computed tomography scan.Am J Surg. 2009; 197: e9-e10Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar Indeed, we have experienced 6 cases of gallbladder rotation from 2003 to 2011, and 5 of these cases (83.3%) exhibited a whirl sign. Gallbladder torsion, which used to be difficult to diagnose preoperatively, can now be definitively diagnosed if clinicians are aware of this disease entity and its clinical findings, especially the “whirl sign.”