Gallbladder, Volvulus

Article Author:
George Mathew
Article Editor:
Steve Bhimji
Updated:
10/27/2018 12:31:36 PM
PubMed Link:
Gallbladder, Volvulus

Introduction

Gallbladder volvulus (GV) is an uncommon condition presenting as an acute abdomen. This condition was first reported by Wendel in 1898 as "floating gallbladder." Urgent surgical intervention is necessary. In a majority of cases, the diagnosis is made intraoperatively. This clinical problem is very rare and accounts for only 1 out of 365,000 cases with gallstone disease.

Etiology

GV, or torsion of the gallbladder, rarely occurs when the gallbladder twists around its mesentery. Contributory factors for this to occur are postulated to be an associated anatomical abnormality of the of the vascular pedicle to the gallbladder or the presence of an abnormally long mesentery from the gallbladder to the liver bed allowing it to float freely. The gallbladder, in this situation, can twist around the axis of the cystic duct and artery. During the process of aging, there is a loss of visceral fat attributed to the higher incidence of gallbladder volvulus in the older age group. The other contributing factors for the development of this condition are the peristaltic activity of the surrounding bowel, spinal deformities, and tortuous atherosclerotic cystic artery.

Epidemiology

Gallbladder volvulus has been reported in many age groups; however, it is most common in the elderly. It commonly affects women in their seventies and eighties. The occurrence in women is higher compared to men at a ratio of 3:1. Mortality associated with this problem is 6%.

Pathophysiology

Gallbladder torsion is now recognized as an acute condition which occurs when the gallbladder twists on its elongated mesentery along the axis of the cystic duct and artery. The presence of gallstones is neither a prerequisite nor thought to contribute to this condition which results from organoaxial-rotation. The resultant pathological consequences in the gallbladder are compromised blood supply resulting in ischemia and necrosis as well obstruction to biliary drainage. The gallbladder becomes more predisposed to hang free and undergo torsion with aging. The torsion can present as either complete or incomplete. When the rotation is more than 180 degrees, it is considered to be complete, but, if the rotation is less than 180 degrees, then it is considered incomplete.

History and Physical

Patients frequently present to the emergency department with an acute abdomen. The symptoms are similar to those of recurrent biliary colic incomplete torsion, but in the presence of complete torsion, there is a short history of sudden-onset of severe upper-right quadrant pain and associated vomiting. A palpable abdominal is sometimes present. There are usually no associated signs of toxemia or jaundice. The preoperative diagnosis of gallbladder torsion remains difficult because the nonspecific symptoms and signs which may be similar to those of acute infective pathology. At times, the findings on clinical examination are similar to that of acute appendicitis or ischaemic bowel. Regardless of rotational direction, blood supply is ultimately compromised, leading to infarction and gangrene. Usually, the patient is admitted with a presumptive diagnosis of infectious etiology requiring resuscitation and appropriate antibiotic therapy.  When symptoms are unremitting in spite of adequate treatment for an acute right-sided abdominal pathology, the index of suspicion in support of volvulus of the gallbladder needs to be high.

Evaluation

The diagnosis of torsion or GV remains a challenge to the surgeon and radiologist despite the availability of advanced laboratory investigations and imaging. Laboratory tests of liver function are often equivocal in incomplete volvulus. White cell count and C-reactive protein level could be raised. Ultrasonography is commonly the first imaging that is performed. Three features are recognized as indicative of gallbladder torsion: (1) a diffusely thickened and hypoechoic gallbladder wall that displays gangrene and inflammation, (2) a floating gallbladder, in which the major part of the organ does not adhere to the liver bed, and (3) a conical structure at the gallbladder neck, consisting of multiple linear echoes converging toward the tip of the “cone." 

Ultrasonography and CT are the primary imaging approaches used for diagnosis. A CT scan can reveal a "floating gallbladder" with gallbladder wall thickening. An accurate interpretation of imaging findings is crucial in diagnosing gallbladder torsion. A magnetic resonance imaging (MRI) can help with the imaging of a twisted cystic duct, and T2 weighted images are beneficial for evaluating necrosis of the gallbladder wall. A HIDA scan, if performed, shows a bullseye image due to the subsequent accumulation of the radio isotope in the gallbladder. Early diagnosis of gallbladder torsion can help to prevent life-threatening complications, such as gallbladder gangrene, perforations causing bilious peritonitis, and other infections. For preventing this sequela, ultrasonography and CT are the primary imaging approaches. Early use of appropriate imaging prevents complications, reduces mortality and morbidity rates, and decreases hospitalization costs.

Upper GI endoscopy may also help with the diagnosis. The diagnosis is often made when there is distortion of the proximal gastric anatomy and difficulty with intubation of the stomach and pylorus. During the later stages, one may observe frank mucosal sloughing, ulceration or even necrosis.

Treatment / Management

When acute GV is diagnosed or highly suspected, urgent surgical intervention is needed. The appropriate surgery is to perform emergency cholecystectomy. Cholecystectomy can be done using open or laparoscopic approaches. The crucial steps during the cholecystectomy involve decompression and derotation of the gallbladder to obtain a clear view of the anatomical structures. Careful and meticulous dissection of the anatomical structure is essential because biliary structures such as the bile duct will be abnormally placed because of the torsion, making it susceptible to iatrogenic injury. The outcome for this condition is excellent when emergency surgery is done, Any delay in surgical intervention can result in infarction and necrosis of the gallbladder which can then lead to bilious peritonitis and increase morbidity and mortality rate.

Pearls and Other Issues

GV or torsion of the gallbladder is a rare condition. It presents a challenge for early diagnosis preoperatively, despite advances in imaging and laboratory investigation. A high index of suspicion in all elderly patients presenting with symptoms suggestive of acute or non-resolving symptoms of cholecystitis will enhance early diagnosis, especially when gallstones are absent. The best patient outcome is achieved with the early use of diagnostic imaging and prompt surgical intervention for removal of the gallbladder. The surgeon's alertness to consider the possibility of this diagnosis will avoid treatment delays that may result in a fatality.