Torsion of the gallbladder: a rare but important differential to consider when treating acute cholecystitis non-operatively

A 79-year-old woman presented with postprandial epigastric pain. She had normal vital signs, inflammatory markers and liver function tests. Ultrasound and CT of the abdomen demonstrated features consistent with acute cholecystitis. Her medical comorbidities and extensive abdominal surgical history prompted the decision to treat non-operatively. Despite optimal medical management, worsening abdominal pain and uptrending inflammatory markers developed. She underwent an emergency laparoscopy which revealed a necrotic gallbladder secondary to an anticlockwise complete gallbladder torsion; a rare condition associated with significant morbidity and mortality if managed non-operatively. Laparoscopic cholecystectomy was achieved without complication and the patient had an uneventful recovery. Preoperative diagnosis of torsion of the gallbladder is difficult. However, there are certain patient demographics and imaging characteristics that can help surgeons differentiate it from acute cholecystitis; a condition which can be safely managed non-operatively in selected patients. The differentiating features are elaborated on in this case report.

A Case of Torsion of the Gallbladder Suspected with SPECT-CT: Review and Recommendations

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.

Volvulus of the Gallbladder: Case Reports

The volvulus of the gallbladder can be considered a clinical curiosity. However, we herein report three recent demonstrative consecutive cases. Female gender, advanced age and a thin constitution seem to represent common predisposing factors. A brutal and excrutiatingly painful presentation in the right hypochondrium contrast initially with seemingly normal vital parameters. Fever can be observed as well as signs of peritoneal irritation. An X-Ray of the abdomen can show a complete emptiness of the right flank and whole blood analysis can reveal an elevated leucocyte count predominantly neutrophilic. The torsion of the gallbladder thus presents itself as an acute cholecystitis with particularities catching the clinician's attention. The only anatomical predisposing factor resides in an anomaly of the mesocyst. The prognosis is driven by the delay to cholecystectomy as a fatal toxinic syndrome can be dreaded in this fragile population. Population's aging and possibilities to enlarge surgical indications in the elderly, enforces us to abandon the pejorative qualifier of « rare curiosity » attached to the gallbladder volvulus and define it as a clear entity in the gallbladder pathology.