Mysterious Gallbladder

Case description:

Previous medical history proved unremarkable except for prior episodes of acute diverticulitis, osteoporosis, and a right bundle branch block. Blood work showed no gross abnormalities. Bilirubin was minimally elevated at 20 umol/l. In addition, the patient presented with a leucocytosis of 14.9 x 10*9/l without elevation in C reactive protein (CRP). Cardiac enzymes were also unremarkable. Due to the nonspecific nature of the patients symptoms, an ultrasound examination was performed. Here, no cholecystolithiasis was present, however some thickening of the gallbladder wall was observed (Figure A).

The appendix and ovaries could not visualized. No free fluid was found in the abdominal cavity. Without a clear diagnosis, the decision was made to observe the patient on the surgical ward over the course of 24 hours. The following day, the patient complained of further pain, this time focused in the mid to lower right abdomen. The physical examination showed a defense in the right lower quadrant. In addition, elevated inflammatory values were observed in the blood. The CRP had increased to 109 mg/l, with leucocytosis of 10.9 x 10*9/l. In addition, the bilirubin had also increased to 44 umol/l. After deliberation, the patient was prepped for same day surgery. A diagnostic laparoscopy was performed.

What was the most likely intraoperativ diagnosis?

A.    Acute appendizitis

B.    Acute cholecystitis

C.     Ovarian torsion

D.    Gallbladder volvulus

E.     Gallbladder malignancy

Case Solution:

Intraoperatively, the gallbladder appeared to have rotated around the cystic duct and artery, with signs of ischemia (Figure B). A gallbladder volvulus was diagnosed and laparoscopic cholecystectomy was performed. The postoperative course was uneventful and the patient discharged at the third hospital day.

Gallbladder volvulus is a rare condition¹. First described in 1898 as a „floating gallbladder, it occurs when the gallbladder twists around its mesentery^2-4. This can be due to a long mesentery or an abnormality of the vascular pedicle^5-6. Other contributing factors include the loss of visceral fat, as can occur with weight loss or aging⁷. Based on this, epidemiologically it shows two peaks³. Its relatively nonspecific clinical and diagnostic presentation complicates its diagnosis and can lead to delays in treatment. However, it presents an important differential diagnosis which must be considered as it can rapidly progress to septicemia due to the resultant ischemia and necrosis⁸.