• child
• diagnosis
• gallbladder torsion
• laparoscopic cholecystectomy
• treatment

• gallbladder ischemia
• laparoscopic cholecystectomy
• pediatric cholecystitis
• viral‐induced acalculous cholecystitis

• Gall bladder
• gall bladder torsion
• gall bladder volvulus

• Humans
• Female
• Child
• Aged
• Infant
• Abdomen, Acute/etiology
• Torsion Abnormality/diagnosis
• Abdominal Pain/etiology
• Gallbladder Diseases/surgery

• gallbladder removal
• gallbladder volvulus
• lap chole
• pediatric laparoscopic surgery
• single-port laparoscopic surgery

Gallbladder volvulus (GBV) is an extremely rare disease, which presents similarly to acute cholecystitis. It has an incidence of less than 0.1% among urgent cholecystectomies and one in 356,000 hospital admissions. We report the case of a 92-year-old female with a three-day history of abdominal pain that had acutely worsened and localized to the right upper quadrant over the past 24 hours. Physical examination revealed a tender palpable mass in the right upper quadrant. Laboratory investigations demonstrated elevation of the white cell count and liver enzymes while CT abdomen showed a thick-walled gallbladder with an abrupt cut-off of the cystic duct suggestive of gallbladder volvulus. A laparoscopic cholecystectomy revealed a massively distended gangrenous gallbladder which has volved on the hepatocystic ligament. We present this case to demonstrate the radiological and intraoperative findings of GBV and to highlight the importance of early intervention to avoid life-threatening complications.

• biliary intervention
• general surgery
• pancreas and biliary tract

• gastrointestinal surgery
• general surgery

• Acute care surgery
• gallbladder torsion
• gallbladder volvulus

•

Accurate preoperative diagnosis of gallbladder torsion is challenging because of the absence of clinical characteristics associated with it.

Gallbladder torsion is mainly associated with a floating gallbladder. From an anatomical perspective, laparoscopic cholecystectomy is a more optimal treatment than open cholecystectomy.

An 84-year-old woman visited the Onomichi General Hospital because of progressive pain in the right upper quadrant of her abdomen. Physical examination revealed a positive Murphy sign and peritoneal irritation. Laboratory data demonstrated that inflammatory marker levels were increased. Abdominal ultrasonography showed that blood flow in the cystic artery was reduced and the gallbladder was swollen. Abdominal contrast-enhanced computerized tomography indicated that the swollen gallbladder was modestly enhanced and the fundus was displaced under the midline and detached from the gallbladder bed. The cystic duct was twisted. Magnetic resonance cholangiopancreatography showed that the root of the cystic duct was unclear and the extrahepatic bile duct had V-shaped distortion. The gallbladder neck showed a tapering interruption with the common biliary duct. We made a preoperative diagnosis of gallbladder torsion. Accordingly, emergency laparoscopic cholecystectomy was performed. The intraoperative findings included a dark swollen gallbladder that was twisted in the counterclockwise direction. The patient was discharged without any postoperative complications on day 7.

Combined acute onset of abdominal pain with characteristic radiological findings made it possible to precisely diagnose gallbladder torsion.

Laparoscopic cholecystectomy can be the gold standard treatment for gallbladder torsion after a preoperative diagnosis is made.

• Cholecystitis
• Floating gallbladder
• Gallbladder torsion

Gall bladder torsion (GBT) is a relatively uncommon entity and rarely diagnosed preoperatively. A constant factor in all occurrences of GBT is a freely mobile gall bladder due to congenital or acquired anomalies. GBT is commonly observed in elderly white females. We report a 77-year-old, Caucasian lady who was originally diagnosed as gall bladder perforation but was eventually found with a two staged torsion of the gall bladder with twisting of the Riedel’s lobe (part of tongue like projection of liver segment 4A). This together, has not been reported in literature, to the best of our knowledge. We performed laparoscopic cholecystectomy and she had an uneventful post-operative period. GBT may create a diagnostic dilemma in the context of acute cholecystitis. Timely diagnosis and intervention is necessary, with extra care while operating as the anatomy is generally distorted. The fundus first approach can be useful due to altered anatomy in the region of Calot’s triangle. Laparoscopic cholecystectomy has the benefit of early recovery.

• Gall bladder torsion
• Gangrenous gall bladder
• Perforated gall bladder
• Two staged torsion of the gall bladder
• Laparoscopic cholecystectomy

• Computed tomography
• Emergency
• Gallbladder
• Gangrenous Cholecystitis
• Volvulus

• Aged
• Bile Duct Diseases/complications
• Bile Duct Diseases/diagnostic imaging
• Bile Duct Diseases/surgery
• Cholecystectomy
• Cholecystitis, Acute/diagnostic imaging
• Cholecystitis, Acute/etiology
• Cholecystitis, Acute/surgery
• Cystic Duct/diagnostic imaging
• Cystic Duct/surgery
• Diagnosis, Differential
• Emergencies
• Female
• Gallbladder/pathology
• Gallbladder Diseases/complications
• Gallbladder Diseases/diagnostic imaging
• Gallbladder Diseases/surgery
• Gangrene
• Humans
• Radiography
• Torsion Abnormality/complications
• Torsion Abnormality/diagnosis
• Torsion Abnormality/diagnostic imaging
• Torsion Abnormality/surgery

Gallbladder torsion is a rare, but potentially lethal disease, in which early recognition is crucial.

We describe the case of an 89-year-old Caucasian woman who presented with clinical symptoms suggestive of acute cholecystitis to our hospital. Radiological imaging confirmed our clinical diagnosis. At first we considered percutaneous gallbladder drainage because of her age and comorbidity, but instead performed laparoscopic cholecystectomy because of rapid clinical deterioration. During laparoscopy a necrotic gallbladder due to torsion of the gallbladder around the cystic duct was found.

Because percutaneous drainage could lead to further deterioration in the case of gallbladder torsion, this rare condition should be considered before performing a percutaneous drainage of cholecystitis.

Acute gallbladder volvulus continues to remain a relatively uncommon process, manifesting itself usually during exploration for an acute surgical abdomen with a presumptive diagnosis of acute cholecystitis. The pathophysiology is that of mechanical organo-axial torsion along the gallbladder's longitudinal axis involving the cystic duct and cystic artery, and with a pre-requisite of local mesenteric redundancy. The demographic tendency is septua- and octo-genarians of the female sex, and its overall incidence is increasing, this being attributed to increasing life expectancy. We discuss two cases of elderly, fragile women presenting to the emergency department complaining of sudden onset right upper quadrant abdominal pain. Their subsequent evaluation suggested acute cholecystitis. Ultimately both were taken to the operating room where the correct diagnosis of gallbladder torsion was made. Pre-operative diagnosis continues to be a major challenge with only 4 cases reported in the literature diagnosed with pre-operative imaging; the remainder were found intra-operatively. Consequently, a delay in diagnosis can have devastating patient outcomes. Herein we propose a necessary high index of suspicion for gallbladder volvulus in the outlined patient demographic with symptoms and signs mimicking acute cholecystitis.