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Acute gallbladder torsion - a continued pre-operative diagnostic dilemma

Mouawad NJ, Crofts B, Streu R, Desrochers R, Kimball BC - World J Emerg Surg (2011)

Bottom Line: Ultimately both were taken to the operating room where the correct diagnosis of gallbladder torsion was made.Pre-operative diagnosis continues to be a major challenge with only 4 cases reported in the literature diagnosed with pre-operative imaging; the remainder were found intra-operatively.Consequently, a delay in diagnosis can have devastating patient outcomes.

Affiliation: Department of General Surgery, Saint Joseph Mercy Health System, Suite R-2111, PO Box 995, Ann Arbor, MI, 48106, USA. nmouawad@gmail.com.

ABSTRACT

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 artery, and with a pre-requisite of local mesenteric redundancy. The demographic tendency is septua- and octo-genarians of the female sex, and its overall incidence is increasing, this being attributed to increasing life expectancy. We discuss two cases of elderly, fragile women presenting to the emergency department complaining of sudden onset right upper quadrant abdominal pain. Their subsequent evaluation suggested acute cholecystitis. Ultimately both were taken to the operating room where the correct diagnosis of gallbladder torsion was made. Pre-operative diagnosis continues to be a major challenge with only 4 cases reported in the literature diagnosed with pre-operative imaging; the remainder were found intra-operatively. Consequently, a delay in diagnosis can have devastating patient outcomes. Herein we propose a necessary high index of suspicion for gallbladder volvulus in the outlined patient demographic with symptoms and signs mimicking acute cholecystitis.

Intraoperative finding. Necrotic gallbladder twisted on its mesentery
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Figure 4: Intraoperative finding. Necrotic gallbladder twisted on its mesentery

Mentions: On entering the abdominal cavity, a gangrenous distended gallbladder with omentum adhesed to it circumferentially was immediately noted (Figure 4). On further careful dissection, it was observed that the gallbladder was twisted on the cystic duct and artery, and the diagnosis of gallbladder volvulus was then made. The gallbladder torsion was reduced and a cholecystectomy was then performed in the usual fashion, with placement of a Jackson-Pratt drain in the gallbladder fossa. The specimen did not contain any gallstones. Histology revealed transmural necrosis consistent with volvulus.

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Acute gallbladder torsion - a continued pre-operative diagnostic dilemma

Mouawad NJ, Crofts B, Streu R, Desrochers R, Kimball BC - World J Emerg Surg (2011)

Intraoperative finding. Necrotic gallbladder twisted on its mesentery
© Copyright Policy - open-access
Figure 4: Intraoperative finding. Necrotic gallbladder twisted on its mesentery
Mentions: On entering the abdominal cavity, a gangrenous distended gallbladder with omentum adhesed to it circumferentially was immediately noted (Figure 4). On further careful dissection, it was observed that the gallbladder was twisted on the cystic duct and artery, and the diagnosis of gallbladder volvulus was then made. The gallbladder torsion was reduced and a cholecystectomy was then performed in the usual fashion, with placement of a Jackson-Pratt drain in the gallbladder fossa. The specimen did not contain any gallstones. Histology revealed transmural necrosis consistent with volvulus.

Bottom Line: Ultimately both were taken to the operating room where the correct diagnosis of gallbladder torsion was made.Pre-operative diagnosis continues to be a major challenge with only 4 cases reported in the literature diagnosed with pre-operative imaging; the remainder were found intra-operatively.Consequently, a delay in diagnosis can have devastating patient outcomes.

Affiliation: Department of General Surgery, Saint Joseph Mercy Health System, Suite R-2111, PO Box 995, Ann Arbor, MI, 48106, USA. nmouawad@gmail.com.

ABSTRACT

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 artery, and with a pre-requisite of local mesenteric redundancy. The demographic tendency is septua- and octo-genarians of the female sex, and its overall incidence is increasing, this being attributed to increasing life expectancy. We discuss two cases of elderly, fragile women presenting to the emergency department complaining of sudden onset right upper quadrant abdominal pain. Their subsequent evaluation suggested acute cholecystitis. Ultimately both were taken to the operating room where the correct diagnosis of gallbladder torsion was made. Pre-operative diagnosis continues to be a major challenge with only 4 cases reported in the literature diagnosed with pre-operative imaging; the remainder were found intra-operatively. Consequently, a delay in diagnosis can have devastating patient outcomes. Herein we propose a necessary high index of suspicion for gallbladder volvulus in the outlined patient demographic with symptoms and signs mimicking acute cholecystitis.

View Similar Images In: Results  - Collection
View Article: PubMed Central - HTML -  PubMed
Show All Figures - Show MeSH
getmorefigures.php?pmc=3083339&rFormat=json&query=null&req=5