Torsion of the gallbladder leading to gangrene: A case report and literature review

Abstract

Gallbladder torsion is a rare but potentially catastrophic presentation to an acute surgical unit. It was first described by Wendel in 1898 where this presentation was labelled as a ‘floating gallbladder’, with a high propensity for perforation1. Since then approximately 500 cases have been reported in the literature2. Anatomically, gallbladder torsion occurs where the gallbladder rotates along its mesentery causing vascular compromise and obstruction to biliary drainage. This leads to subsequent necrosis and perforation3. Shaikh A. et al have reiterated that the entire aetiological sequence of gallbladder torsion continues to remains a debated topic although, generally, a redundant mesentery is required for torsion to occur4. In most reported cases, the gallbladder has been shown to undergo a clockwise rotation 5. As described later, this presentation has predominantly been reported in elderly females suggesting that age plays a role in anatomically predisposing to torsion. Factors hypothesised for this include decrease in visceral fat and liver atrophy making free movement of the gallbladder and ultimately volvulus more likely to occur6. The symptoms of gallbladder torsion are in keeping with those of cholecystitis, typically presenting with right upper quadrant pain, nausea and vomiting 2. Clinical examinations of previously reported cases have documented abdominal distention, right upper quadrant pain and localised peritonitis2. These non-specific signs can make this specific phenomenon a challenge to diagnose in clinical practice. It has been documented that a partial volvulus can present with intermittent symptoms, similar to those seen in biliary colic, although the majority of cases will present acutely with signs described above 3. Due to the relatively low numbers reported in the literature it is difficult to determine the most appropriate investigations in patients where this is expected. Classically, patients presenting with right upper quadrant pain will likely receive an abdominal ultrasound on admission. From the cases reported we have found that a range of investigations have been implemented in practice including ultrasound and computed tomography (CT), although this diagnosis is often pragmatically difficult to diagnose based on imaging alone 3. Non-specific findings of gallbladder inflammation have been reported in cases of gallbladder torsion including gallbladder wall thickening and fluid collections surrounding the gallbladder neck 7. Other imaging modalities useful in pre-operative diagnosis include Magnetic Resonance Cholangiopancreatography (MRCP) which may show tapering and twisting of the cystic duct 3, 8. Interestingly, gallbladder calculi have not been considered a causative factor and where present in less than a third of patients carrying this diagnosis in a review performed by Reilly et al 5, 9. Other baseline investigations including white cell count, CRP and liver function tests have been shown to be relevant in diagnosing the acute abdomen. However, these are generally non-specific as a predictor for gallbladder volvulus. Reilly et al performed a systematic review of 324 cases shown in the literature between 1898 and 2011 9. From this the predominant risk factors associated with gallbladder volvulus include female sex, age over 60 years and patients with several comorbidities 9 Previous authors have suggested that female to male ratios in presentation are approximately 4:1, although the condition is more prevalent in males in children 10. Management of this condition is primarily surgical and the reports published show that these patients are mainly treated by cholecystectomy. In general, this is done laparoscopically in experienced hands where this presentation is identified 3, 4, 9. It has been suggested that the gallbladder should first be decompressed if distended to allow for a more straightforward removal 3. There has also been a case reported managed with ERCP although this is not the preferred method of managing this condition 11. Prognosis of this condition is dependent on several factors. The literature has demonstrated that those patients with a pre-operative diagnosis have more favourable outcomes 9. Reilley et al suggested from their review that overall mortality was approximately 6% 9. In this report we discuss the case of gallbladder torsion managed at a large district hospital in North East England.