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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 87-90

Gallbladder volvulus in a patient with chronic lymphocytic leukemia treated with laparoscopic cholecystectomy


1 Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
2 Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA

Date of Web Publication26-Jun-2019

Correspondence Address:
Dr. Benjamin B Scott
110 Francis Street, Suite 9B, Boston, Massachusetts 02215
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCIIS.IJCIIS_81_18

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   Abstract 


Gallbladder volvulus is a rare condition that most commonly occurs in elderly women and often mimics acute cholecystitis in its presentation. This condition is a surgical emergency requiring cholecystectomy as it can lead to gallbladder perforation and bilious peritonitis with high morbidity to the patient. An 85-year-old woman with chronic lymphocytic leukemia presented with acute-onset right upper-quadrant abdominal pain and associated nausea with emesis. After admission to the surgical service and initiation of intravenous antibiotics, the patient was taken to the operating room for surgical management due to the persistence of symptoms. Intraoperative findings included a necrotic appearing gallbladder that was twisted on the cystic duct. Laparoscopic cholecystectomy was performed, which was complicated by bile leak requiring endoscopic retrograde cholangiopancreatography with bile duct stenting followed by operative washout. Gallbladder volvulus can be challenging to diagnose. This condition should be suspected in elderly women with acute-onset abdominal pain and imaging concerning for acute cholecystitis. Emergent cholecystectomy is the treatment of choice for gallbladder volvulus.

Keywords: Acute care surgery, gallbladder torsion, gallbladder volvulus


How to cite this article:
Scott BB, Guo L, Santiago J, Cook CH, Parsons CS. Gallbladder volvulus in a patient with chronic lymphocytic leukemia treated with laparoscopic cholecystectomy. Int J Crit Illn Inj Sci 2019;9:87-90

How to cite this URL:
Scott BB, Guo L, Santiago J, Cook CH, Parsons CS. Gallbladder volvulus in a patient with chronic lymphocytic leukemia treated with laparoscopic cholecystectomy. Int J Crit Illn Inj Sci [serial online] 2019 [cited 2019 Jul 23];9:87-90. Available from: http://www.ijciis.org/text.asp?2019/9/2/87/261463




   Introduction Top


Gallbladder volvulus is an uncommon condition that can mimic acute cholecystitis. Since first described by Wendel in 1898,[1] approximately 500 cases have been reported.[2] This condition is seen most commonly in elderly women, and as described by Gross in 1936, is associated with loss of adhesions between the liver and gallbladder.[3] This anatomical abnormality allows the gallbladder to rotate partially or completely on its long axis, resulting in compromised vascular perfusion to the gallbladder.[4] Preoperative diagnosis is challenging due to symptoms, laboratory assays, and radiographic imaging that are similar to those of acute cholecystitis.[5] It is usually diagnosed intraoperatively, and the treatment is detorsion and cholecystectomy.[6] We report the case of an elderly woman initially diagnosed with acute cholecystitis who was found intraoperatively to have complete gallbladder volvulus that was treated with laparoscopic cholecystectomy.


   Case Report Top


An 85-year-old woman presented to the emergency department with complaints of acute-onset abdominal pain. She reported a 1-day history of epigastric pain that radiated to the right upper quadrant and right flank. It was associated with anorexia, nausea, and emesis. She denied fever, chills, change in bowels, or any other symptoms. She was afebrile with mild tachycardia at initial presentation. Physical examination was notable for a soft, nondistended abdomen with tenderness to palpation in the epigastrium and right upper quadrant. She was found to have a positive Murphy sign. Her past medical history was significant for chronic lymphocytic leukemia for which she was currently treated with ibrutinib. Laboratory assay revealed a white blood cell count of 168.7, which was within her baseline levels. Her liver function tests were normal, with a total bilirubin of 0.5, alkaline phosphatase of 98, and normal transaminases. A computed tomography (CT) scan of the abdomen revealed a dilated gallbladder with a thickened wall and pericholecystic edema concerning for acalculous cholecystitis [Figure 1]. No obvious gallstones were noted. An ultrasound of the right upper quadrant was obtained in order to attempt to better visualize gallstones. This ultrasound did not visualize gallstones or sludge, but did confirm the presence of a distended gallbladder with a thickened wall. She was admitted to the general surgery service, and intravenous ciprofloxacin and metronidazole were administered [Table 1]. Due to the persistence of symptoms, she was taken to the operating room for laparoscopic cholecystectomy with a presumed diagnosis of acute cholecystitis. After the induction of general anesthesia, she had a palpable mass in the right upper quadrant. Upon insertion of the laparoscope into the abdomen, it was noted that the gallbladder was completely gangrenous. There was only one attachment from the underside of the liver to the gallbladder, which measured approximately 1 cm. Distal to this attachment, the gallbladder was completely torsed. After detorsion, the infundibulum was also noted to be gangrenous, but the proximal cystic duct was not, and laparoscopic cholecystectomy was performed. Given the very short attachment of the gallbladder to the liver fossa, great care was taken to completely define the anatomy prior to resection. The total operative time was 135 min with minimal blood loss. Histopathologic findings of the gallbladder specimen revealed acute cholecystitis with involvement by chronic lymphocytic leukemia. Postoperatively, her course was complicated by abdominal distention, right shoulder pain, and hyperbilirubinemia. On postoperative day #3, a repeat ultrasound of the right upper quadrant was performed, which revealed a small amount of perihepatic fluid concerning for bile leak. There was no choledocholithiasis or intrahepatic biliary dilatation. A hepatobiliary iminodiacetic acid (HIDA) scan confirmed leakage of the bile posteriorly and at the dome of the liver. The patient then underwent endoscopic retrograde cholangiopancreatography that showed normal biliary anatomy with peripheral bile leakage therefore a common bile duct stent was placed. She had a CT scan of the abdomen on postoperative day #4 for persistent symptoms, revealing persistent biloma measuring 11 cm at the greatest diameter. She returned to the operating room for laparoscopic washout and drain placement. The patient was discharged to home on postoperative day #9/#5. One week after the discharge, the patient had her drain removed in the outpatient clinic and after further recovery, her biliary stent was removed endoscopically.
Figure 1: Gallbladder volvulus. (a) Coronal reconstruction of contrast-enhanced computed tomography demonstrates a distended and conical gallbladder freely suspended outside its normal anatomic fossa, associated with pericholecystic fluid and mild intrahepatic ductal dilatation. The transition from the distended lumen to the angulated and abruptly tapered infundibulum may resemble a curved beak at the suspected point of twist (arrow). (b) Gray-scale ultrasound image shows diffuse thickening of the gallbladder wall with trace pericholecystic fluid but no intraluminal stones or sludge

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Table1: Timeline of events for case

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   Discussion Top


Gallbladder volvulus, also known as gallbladder torsion, refers to the twisting of the gallbladder around its mesentery. First described by Wendel in 1898, it remains a rare phenomenon as approximately only 500 cases have been reported in the literature.[1],[7] The condition is most prevalent in elderly women, but has also been documented in pediatric populations.[8],[9] It typically presents as acute-onset right upper-quadrant pain and is frequently misdiagnosed as acute acalculous cholecystitis, as in the current report.

Gallbladder volvulus is associated with a “free-floating” gallbladder, in which there is minimal fixation of the gallbladder to the liver bed. This configuration is associated with an abnormal gallbladder mesentery which allows the gallbladder to twist along the axis of the cystic artery and duct.[10] The Gross classification describes two anatomical variants of gallbladder mesentery.[3] In Type I, the mesentery is wide and attached to the cystic duct as well as a portion of the gallbladder body. In Type II, the mesentery only supports the cystic duct and artery. These characteristic mesenteries have been postulated to occur congenitally or are acquired through loss of fat, liver atrophy or visceroptosis, and the relaxation and atrophy of previously normal mesentery in the elderly.[11] Triggers for gallbladder torsion have also been proposed, including vigorous peristalsis of the neighboring organs.[8] Kyphoscoliosis and atherosclerosis of the cystic artery may contribute as fulcrums for torsion.[12] Interestingly, cholelithiasis does not appear to play a dominant role in the development of volvulus, as a review of 235 cases in the Japanese literature found gallstones in only ~25% of patients afflicted.[13]

Diagnosing gallbladder volvulus preoperatively is challenging due to low prevalence, nonspecific radiographic findings, and a clinical presentation that mimics acute cholecystitis. Sonographic features are often nonspecific to gallbladder volvulus, such as gallbladder wall thickening and pericholecystic fluid.[14] However, findings of the gallbladder out of the fossa, conical shape, and/or floating anteriorly without gallstones should increase should increase suspicion for gallbladder torsion.[4],[15] Doppler imaging may be helpful to demonstrate compromised blood flow.[16] CT of the abdomen may show abnormal positioning and impairment of blood flow, but is not specific to gallbladder volvulus.[5] Magnetic resonance imaging of the abdomen has also been utilized in the pediatric population for diagnosis.[8],[9] HIDA scan and magnetic resonance cholangiopancreatography (MRCP) are additional imaging modalities reportedly utilized to help diagnose gallbladder volvulus. Tracer accumulation can lead to a “bull's eye” appearance of the gallbladder on HIDA scan,[16] and MRCP can reveal gallbladder dilatation and often twisting of the cystic duct.[17]

A review of the literature found that only 9.8% of the reported cases of gallbladder volvulus were correctly identified preoperatively.[18] Due to challenges with diagnosing gallbladder volvulus, Lau et al. proposed the “Triad of Triads” [Table 2] comprising factors related to appearance (elderly female, thin, and spinal deformities), symptoms (sudden onset, right upper-quadrant pain, and early emesis), and physical examination findings (nontoxic presentation, palpable right upper-quadrant mass, and pulse–temperature discrepancy), in order to more easily identify potential patients with the condition.[19]
Table2: Triad of triads for early recognition of potential gallbladder volvulus[19]

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Prompt diagnosis is critical in the management of gallstone volvulus because progression to necrosis is rapid once torsion has occurred. Delay in intervention can result in perforation and bilious peritonitis, which increases the associated mortality to approximately 5%.[20] Emergent cholecystectomy is the preferred treatment for gallbladder volvulus upon diagnosis.[5] The laparoscopic approach is appropriate, as the long mesentery and separation of the gallbladder from the liver bed may ease laparoscopic removal of the gallbladder. Laparoscopic cholecystectomy also results in quicker postoperative recovery. It is important to note that delay in diagnosis resulting in progression to necrosis can lead to increased difficulty in the identification of anatomical structures, often necessitating laparotomy.[10] To facilitate early postoperative recovery for patients with gallbladder volvulus, swift diagnosis and surgical intervention are essential.


   Conclusion Top


Gallbladder volvulus is a relatively rare condition that can be an elusive diagnosis. The condition is most prevalent in elderly women presenting with right upper-quadrant pain and a mass on physical examination, and suspicion should be heightened if symptoms are refractory to antibiotic therapy. Once diagnosed, emergent cholecystectomy is indicated to prevent gallbladder necrosis, perforation, and bilious peritonitis.

Informed consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initial will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Wendel AV. VI. A Case of floating gall-bladder and kidney complicated by cholelithiasis, with perforation of the gall-bladder. Ann Surg 1898;27:199-202.  Back to cited text no. 1
    
2.
Reilly DJ, Kalogeropoulos G, Thiruchelvam D. Torsion of the gallbladder: A systematic review. HPB (Oxford) 2012;14:669-72.  Back to cited text no. 2
    
3.
Gross R. Congenital anomalies of the gallbladder: A review of one hundred and forty-eight cases with report of a double gallbladder. Arch Surg 1936;32:131-62.  Back to cited text no. 3
    
4.
Bagnato C, Lippolis P, Zocco G, Galatioto C, Seccia M. Uncommon cause of acute abdomen: Volvulus of gallbladder with necrosis. Case report and review of literature. Ann Ital Chir 2011;82:137-40.  Back to cited text no. 4
    
5.
Bekki T, Abe T, Amano H, Fujikuni N, Okuda H, Sasada T, et al. Complete torsion of gallbladder following laparoscopic cholecystectomy: A case study. Int J Surg Case Rep 2017;37:257-60.  Back to cited text no. 5
    
6.
Tarhan OR, Barut I, Dinelek H. Gallbladder volvulus: Review of the literature and report of a case. Turk J Gastroenterol 2006;17:209-11.  Back to cited text no. 6
    
7.
Pottorf BJ, Alfaro L, Hollis HW. A clinician's guide to the diagnosis and management of gallbladder volvulus. Perm J 2013;17:80-3.  Back to cited text no. 7
    
8.
Kimura T, Yonekura T, Yamauchi K, Kosumi T, Sasaki T, Kamiyama M, et al. Laparoscopic treatment of gallbladder volvulus: A pediatric case report and literature review. J Laparoendosc Adv Surg Tech A 2008;18:330-4.  Back to cited text no. 8
    
9.
Kitagawa H, Nakada K, Enami T, Yamaguchi T, Kawaguchi F, Nakada M, et al. Two cases of torsion of the gallbladder diagnosed preoperatively. J Pediatr Surg 1997;32:1567-9.  Back to cited text no. 9
    
10.
Vedanayagam MS, Nikolopoulos I, Janakan G, El-Gaddal A. Gallbladder volvulus: A case of mimicry. BMJ Case Rep 2013;2013. pii: bcr2012007857.  Back to cited text no. 10
    
11.
McHenry CR, Byrne MP. Gallbladder volvulus in the elderly. An emergent surgical disease. J Am Geriatr Soc 1986;34:137-9.  Back to cited text no. 11
    
12.
Mouawad NJ, Crofts B, Streu R, Desrochers R, Kimball BC. Acute gallbladder torsion – A continued pre-operative diagnostic dilemma. World J Emerg Surg 2011;6:13.  Back to cited text no. 12
    
13.
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;6:418-21.  Back to cited text no. 13
    
14.
Garciavilla PC, Alvarez JF, Uzqueda GV. Diagnosis and laparoscopic approach to gallbladder torsion and cholelithiasis. JSLS 2010;14:147-51.  Back to cited text no. 14
    
15.
Gonzalez-Fisher RF, Vargas-Ramirez L, Rescala-Baca E, Dergal-Badue E. Gallbladder volvulus. HPB Surg 1993;7:147-8.  Back to cited text no. 15
    
16.
Wang GJ, Colln M, Crossett J, Holmes RA. “Bulls-eye” image of gallbladder volvulus. Clin Nucl Med 1987;12:231-2.  Back to cited text no. 16
    
17.
Fukuchi M, Nakazato K, Shoji H, Naitoh H, Kuwano H. Torsion of the gallbladder diagnosed by magnetic resonance cholangiopancreatography. Int Surg 2012;97:235-8.  Back to cited text no. 17
    
18.
Liu Y, Wu H. Gallbladder volvulus treated by laparoscopic cholecystectomy. Formos J Surg 2013;46:131-4.  Back to cited text no. 18
    
19.
Lau WY, Fan ST, Wong SH. Acute torsion of the gall bladder in the aged: A re-emphasis on clinical diagnosis. Aust N Z J Surg 1982;52:492-4.  Back to cited text no. 19
    
20.
Campione O, D'Alessandro L, Grassigi A, Pasqualini E, Marrano N, Lenzi F. Volvulus of the gallbladder. Minervac Chir 1998;53:285-7.  Back to cited text no. 20
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2]



 

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