Received date: 06/12/2016; Accepted date: 02/01/2017; Published date: 10/01/2017
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Gallbladder torsion is one of the important causes of acute abdomen. Early diagnosis and treatment is important because surgical intervention is required. Abdominal ultrasonography (US) and contrast-enhanced computed tomography (CT) are useful diagnostic tools prior to surgery. Here, we present the case of an elderly woman who underwent emergency cholecystectomy due to gallbladder torsion.
Gallbladder torsion, Acute abdomen.
CT: Computed Tomography, US: Ultrasonography
Patients with right upper quadrant pain are often seen in the emergency department. Most of these are cases of acute cholecystitis. The symptoms of acute cholecystitis are similar to gallbladder torsion, and it is difficult to diagnose the underlying condition before surgery. Although gallbladder torsion is rare, doctors should be familiar with this condition and it should be included in the differential diagnosis of acute abdomen.
An 89 year old Japanese woman with hypertension was admitted to our hospital due to the acute onset of severe right upper quadrant pain, without fever. Her vital signs were within normal limits. Physical examination revealed severe right upper quadrant tenderness with a negative Murphy’s sign. Her laboratory data revealed the following: Hemoglobin level, 12.2 g/dl; white cell count, 8300/μl; platelets 10.6 × 104/μl; C reactive protein, 9.49 mg/dl; aspartate aminotransferase, 30 U/l; alanine aminotransferase, 26 U/l; lactate dehydrogenase, 280 U/l; total bilirubin, 1.18 mg/dl; blood urea nitrogen (BUN) 20.9 mg/dl; serum creatinine level 0.74 mg/dl; alkaline phosphatase, 217 U/l; and gamma-glutamyl transpeptidase, 53 U/l. Abdominal ultrasonography revealed an enlarged gallbladder without blood flow (Figure 1).
Contrast-enhanced CT in the coronal view showed a swollen gallbladder without enhancement (Figure 2). According to the physical examination and diagnostic imaging, a diagnosis of gallbladder torsion was obtained, and acute laparoscopic cholecystectomy was subsequently performed. The cholecystectomy specimen exhibited thickened walls and necrosis (Figure 3.A and 3.B). After surgery, the patient was discharged from the hospital on the eighth post-operative day, without complications.
This case provided two important clinical messages.
First, gallbladder torsion is rare but one of the important differential diagnoses of acute abdomen because it requires emergent surgery . Without treatment, life-threatening complications, such as gallbladder gangrene, gallbladder perforation and bilious peritonitis occur . However, it is difficult to diagnose before surgery. According to a previous report, less than 10% of cases are diagnosed as gallbladder torsion before surgery . Patients with right upper quadrant pain are frequently encountered and most of the cases are of acute cholecystitis. The symptoms of gallbladder torsion are similar to that of acute cholecystitis  and gallbladder torsion is frequently misdiagnosed as acute cholecystitis because no single clinical, serologic or radiographic finding is lesion specific . There are several risk factors about gallbladder torsion are known; age over 70 years, female sex, weight loss, liver atrophy, kyphoscoliosis, atherosclerosis, elongated mesentery and loss of visceral fat . When we see the patient with right upper quadrant pain and has these characteristics, we should be aware of this rare disorder. Early diagnosis and adequate intervention of gallbladder torsion prevents poor outcome.
Second, various imaging techniques are useful tools for diagnosis , such as abdominal US and abdominal CT. The abdominal US picture of gallbladder torsion is similar to that of acute cholecystitis . To distinguish these two diseases, there are several findings are known. When the gallbladder is located outside of the fossa and inferior to the liver, this abnormal location can help the diagnosis of gallbladder torsion . Color Doppler of US is useful for visualizing blood flow and gallbladder torsion shows ischemic change . Cholelithiasis visualized on US may support a diagnosis of acute calculous cholecystitis . According to Nakao’s review, in patients with gallbladder torsion, only 24.4% had coexistent cholelithiasis . We should perform abdominal US on multiple occasions to make early diagnosis. Then, contrast enhanced CT images is also beneficial to discover gallbladder torsion. Contrast enhanced CT can detect abnormal location of the gallbladder without blood flow, swirl sign of the cystic duct  and gallbladder is more distended in torsion than in acute cholecystitis . Sharon et al. reported that threedimensional reconstructed CT assisted us to establish a diagnosis preoperatively and proceeded surgery without delay . In our case, combination of abdominal US and contrast enhanced CT findings can make the diagnosis of this rare condition.
Knowledge of both clinical and imaging studies can facilitate preoperative diagnosis.
Gallbladder torsion is a rare disease requiring operative treatment. Diagnostic imaging aids early diagnosis and treatment.
Written informed consent was obtained from the patient for publication of this case and accompanying images. A copy of written consent is available for review by the Editor-in-Chief of this journal.
Yoshiaki Hirohata performed surgery. Both authors read and approved the final manuscript.