Neal Shah, DO1, Jigar Patel, MD1, Eric Ballecer, MD1, Iman Hanna, MD1, Galina Levin, MD2, Michael Khalife, MD1, Alexander Sy, MD3; 1Winthrop University Hospital, Mineola, NY; 2Memorial Sloan-Kettering Cancer Center, Uniondale, NY; 3Jackson Memorial Hospital, Miami, FL
Introduction: Gallbladder volvulus is a rare yet however presenting with increasing incidence. It occurs when the organ twists along its long axis to the point of vascular compromise and can present with either abdominal mass, pain, nausea and vomiting possibly mimic many other disease processes. We present a case of an elderly female with gallbladder volvulus that experienced acute lower abdominal pain in the setting of a palpable abdominal mass.
Methods: 86 year-old woman with severe, sharp epigastric pain radiating to the right lower quadrant associated with nausea and vomiting. Inspection of the abdomen revealed a localized distention, tenderness of the RLQ with a well-defined mass and voluntary guarding. CT abdomen shown no evidence of obstruction or appendicitis. Patient was medically treated initially; however due to worsening WBC count and persistent symptoms; underwent emergent laparoscopic cholecystectomy revealing an ischemic gallbladder. Pathology shown acute hemorrhagic necrosis of the gallbladder without any stones. Discussion: Delay in diagnosis and treatment can be life-threatening. Preoperative radiologic diagnosis is challenging as the twist may not be well seen. Ultrasound is the preferred modality, commonly demonstrating signs of acute cholecystitis. Gallstones are present in only 30% of cases of torsion and are not believed to play a role clinically. Wall abnormalities are best seen on CT scan including thickening and defective wall uptake in the presence of ischemia. A horizontal gallbladder located outside of the gallbladder bed and torsion of the cystic pedicle called “whirl sign” is also noted. HIDA scan shows a “bullseye” image secondary to accumulation of the radioisotope in the gallbladder. MRI findings include high signal intensity within the gallbladder wall on T1 weighted images, suggesting necrosis and hemorrhage that may be seen with torsion as well as gangrenous cholecystitis. MRCP may demonstrate more anatomic detail of the neck of the gallbladder and cystic duct due to high contrast resolution of this modality. However volvulus is not usually discovered until surgical intervention like in our case as the CT scan was not fully conclusive for torsion. The mortality rate is estimated to be 6%, notably in elderly patients with comorbidities. Early diagnosis will help prevent life-threatening complications such as gangrene, perforations causing bilious peritonitis, and other infections. A high degree of clinical suspicion is needed to minimize complications.
At lower magnification the wall of the gallbladder shows transmural necrosis, vascular congestion, hemorrhage and acute inflammation.
Grossly the gallbladder is enlarged, distended and congested.
Axial CT image of the abdomen performed without intravenous contrast demonstrates a distended, horizontally positioned gallbladder. The actual twist in the gallbladder neck is not well seen. There is no pericholecystic inflammation and no appreciable gallbladder wall thickening.
Disclosures: Neal Shah indicated no relevant financial relationships. Jigar Patel indicated no relevant financial relationships. Eric Ballecer indicated no relevant financial relationships. Iman Hanna indicated no relevant financial relationships. Galina Levin indicated no relevant financial relationships. Michael Khalife indicated no relevant financial relationships. Alexander Sy indicated no relevant financial relationships.