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Complete gallbladder torsion diagnosed with sequential computed tomography scans: a case report
© Koyanagi and Sato; licensee BioMed Central Ltd. 2012
Received: 13 March 2012
Accepted: 6 June 2012
Published: 11 September 2012
Torsion of the gallbladder is an extremely rare cause of acute abdomen, which commonly affects thin elderly women. A prompt surgical approach is necessary to avoid fatal complications associated with gangrene and perforation of the gallbladder. However, it is difficult to make a preoperative diagnosis using ordinary imaging modalities.
An 84-year-old Japanese woman was admitted to our hospital due to left lower abdominal pain. Her pain shifted suddenly to the right upper abdomen a half day after admission. Although her enlarged and wall-thickened gallbladder had been already seen at admission, it rotated approximately 180 degrees and deviated to the midline of her abdomen on the second computed tomography scan, which helped us to make a correct diagnosis of gallbladder torsion. The patient underwent an emergency operation (detorsion and cholecystectomy) and recovered without any complications. The gallbladder had necrosis due to torsion.
Sequential diagnostic imaging might be helpful to make a preoperative diagnosis of gallbladder torsion when the gallbladder is enlarged and wall thickened but the patient does not present with typical clinical symptoms.
Torsion of the gallbladder is an extremely rare condition that was first reported in 1898 by Wendel . It has been reported to occur more commonly in thin elderly women and the incidence appears to be increasing, possibly related to an increasingly ageing population [2, 3]. Clinical symptoms and signs of gallbladder torsion include severe right upper abdominal pain and vomiting with sudden onset, palpable abdominal mass, and absence of jaundice and fever . The results of laboratory investigations including liver function tests and biliary enzymes are usually within normal limits . Although prompt surgery is necessary to avoid high mortality associated with gangrene and perforation of the gallbladder, it is difficult to make a preoperative diagnosis of gallbladder torsion.
We report here a case of torsion of the gallbladder in an elderly woman without typical clinical symptoms, in which sequential computed tomography (CT) scans helped us to make a correct diagnosis preoperatively.
There are two types of gallbladder torsion : one is incomplete torsion (rotation less than 180 degrees) with gradual onset, and the other is complete torsion (rotation more than 180 degrees) with acute onset. When this patient was admitted to our hospital, her chief complaint was left lower abdominal pain and no right upper abdominal pain was complained of; her enlarged and wall-thickened gallbladder was seen on the CT scan. We therefore diagnosed her condition as acute enterocolitis or subileus and chose conservative treatment. Evaluating retrospectively, the gallbladder torsion was considered incomplete at the time of admission. After a half day, she suddenly presented with a severe right upper abdominal pain. The second CT scan showed that the gallbladder had rotated approximately 180 degrees and had deviated to the midline of her abdomen. Taking these findings into account, at this time her gallbladder was thought to be free hanging and a diagnosis of gallbladder torsion was clinically assumed. Actually, complete torsion was observed during an emergency operation. Although it is unclear why she presented with left lower abdominal pain at first, it is possible that enterocolitis or subileus occurred due to the intestinal inflammation spreading from the torsed gallbladder.
The decisive findings of gallbladder torsion are described in the literature as left-sided enlarged gallbladder, thickened gallbladder wall without enhancement effect, and a cystic duct located on the right side of the gallbladder [7, 8]. However, it is quite rare for clinicians to make a correct preoperative diagnosis of torsion of the gallbladder based on ordinary radiographic findings. Therefore, as in the present case, chronological diagnostic imaging including CT scans might be helpful when a patient presents with gradual clinical symptoms or atypical symptoms such as lower abdominal pain with an enlarged and wall-thickened gallbladder. In addition, it has been increasingly reported that novel imaging modalities, such as multi-detector row CT, magnetic resonance imaging (MRI), and magnetic resonance cholangiopancreatography also help preoperative diagnosis .
As for the treatment for torsion of the gallbladder, prompt detorsion and cholecystectomy are required to avoid potentially fatal sequelae of gangrene and perforation of the gallbladder . We chose open cholecystectomy in the present case because we could not completely exclude the possibility of bile duct malignancy (painless gallbladder swelling and wall thickening in an elderly patient). However, the effectiveness of laparoscopic cholecystectomy has also been reported . Because adhesion between the gallbladder and the adjacent organs is usually mild, which may facilitate gallbladder torsion, it is relatively easy to dissect the gallbladder from the liver bed and to cut the cystic duct and cystic artery. Therefore, laparoscopic procedures are recommended for the treatment of gallbladder torsion.
Torsion of the gallbladder is a rare cause of acute abdomen and it is difficult to diagnose preoperatively. It is important to take this disease into consideration in the differential diagnosis of acute abdomen in all elderly patients. Moreover, sequential diagnostic imaging including CT scans might be helpful when the gallbladder is enlarged and wall thickened but the patient does not present with typical clinical symptoms.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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