GALLBLADDER TORSION

Torsion of the gallbladder is a rare cause of cholecystitis. The incidence is estimated at 1 in every 365.520 hospital admissions.¹ The first case was described by Wendel in 1898.² It is a condition mainly seen in elderly women, and the incidence appears to increase with increased life expectancy.³ Torsion of the gallbladder can only occur in patients with anatomic variation of gallbladder fixation to the liver. This could be a complete, but too long and wide mesentery or an incomplete mesentery covering only the cystic duct and artery. In these anatomic variations, there is a free-floating gallbladder. Another possibility is that relaxation and atrophy of a previously normal mesentery in the elderly cause visceroptosis.^4,5 Gross⁷ has classified congenital floating gallbladder into two types: type I is defined as attachment of the gallbladder and cystic duct to the inferior surface of the liver via the mesentery, and type II involves attachment of only the cystic duct to the liver.

The causation of gallbladder torsion is uncertain. Two types of anomalies have been implicated in the majority of cases, as well as a third, less common condition. The first type of anomaly occurs between the 4th and 7th weeks of embryological development. During this period, the pars cystica forms from the hepatic diverticulum. Abnormal migration with an absence of a gallbladder mesentery creates a free-floating gallbladder.¹¹ The second type of anomaly occurs by visceroptosis. The mesentery of the gallbladder and cystic duct relaxes and elongates, creating a mobile situation.⁷ Atrophy of the liver⁸ and a general decrease in the elasticity of tissues with aging and multiparity¹¹ have been postulated as possible etiologies. The rare third condition—reported only twice^{9, 10} occurs when a partial portion of the fundus is not fixed to the liver bed. The remainder is attached with a normal mesentery to a foreshortened fossa.

It is possible to feel a movable mass in the right hypochondrium or the right fossa iliaca.¹³ Whipple and Sabo stated that the lower position of the gallbladder may result in a preoperative diagnosis of acute appendicitis.¹² According to Short and Paul, it is possible to perform an accurate presurgery diagnosis for the case we are studying. “The acute pain and vomiting, without jaundice,  in an elderly female and the appearance within a few hours of the onset of the greatly enlarged and palpable gallbladder, are highly suggestive.”¹⁴

Prompt cholecystectomy is the appropriate treatment for either gallbladder torsion or emphysematous holecystitis.^3,6 While the mortality of patients with gallbladder torsion is 100% in unoperated cases, it is only 3%-5% when surgery is performed promptly.^3,11 On the other hand, Garcia-Sancho Tellez et al.⁶ have reported that mortality in patients with emphysematous cholecystitis reached 25%, but in our patient the prompt performance of surgery soon after the detection of emphysematous cholecystitis may have contributed to the good outcome. In general, when acute acalculous cholecystitis is found in young patients without underlying diseases, the possibility of gallbladder torsion should be kept in mind, because if diagnosis is delayed life threatening emphysematous cholecystitis may develop.

Reference

1.        Yeh HC, Weiss MF, Gerson CD. Torsion of the gallbladder: the ultrasonographic features. J Clin Ultrasound 1989 Feb;17 (2):123–5.

2.        Wendel AV. VI. A Case of Floating Gall-Bladder and Kidney complicated by Cholelithiasis, with Perforation of the Gall-Bladder. Ann Surg 1898 Feb;27(2):199–202.

3.        Nakao A, Matsuda T, Funabiki S, Mori T, Koguchi K, Iwado T, et al. Gallbladder torsion: case report and review of 245 cases reported in the Japanese literature. J Hepatobiliary Pancreat Surg 1999;6(4):418–21.

4.        Lemonick DM, Garvin R, Semins H. Torsion of the gallbladder: a rare cause of acute cholecystitis. J Emerg Med 2006 May;30 (4):397–401.

5.        Gupta V, Singh V, Sewkani A, Purohit D, Varshney R, Varshney S. Torsion of gall bladder, a rare entity: a case report and review article. Cases J 2009;2:193.

6.        Garcia-Sancho Tellez L, Rodriguez-Montes JA, Fernandez de Lis S, Garcia-Sancho Martin L. Acute emphysematous cholecystitis. Report of 20 cases. Hepatogastroenterology 1999;46:2144–8.

7.        Gross LE. Congenital anomalies of gallbladder. Arch Surg 1936;32:131–62.

8.        Levene A (1958) Acute torsion of the gallbladder. Br J Surg 45:338–340

9.        Rossouw J (1970) Torsion of the gallbladder: a case where the gallbladder was firmly attached to the liver. S Afr Med J 44: 47–48

10.    Schlinkert RT, Mucha P Jr, Farnell MB (1984) Torsion of the gallbladder. Mayo Clin Proc 59: 490–492

11.    Stieber AC, Bauer JJ (1983) Volvulus of the gallbladder. Am J Gastroenterol 78: 96–98

12.    Whipple RD, Sabo RR: Acute torsion of the gallbladder. Am J Surg 137:789–789, 1979

13.    Taziaux P, Pans A, Lismonde M, Namur M, Hermans G,Wahlen C: Le volvulus de la v´esicule biliaire. J Chir 127:408–411, 1990

14.    Short AR, Paul RG: Torsion of the gallbladder. Br J Surg 22:301–309, 1934