Elizabeth E Price, DO, Luciano Dimarco, DO. UPMC Pinnacle Community Osteopathic Hospital
Gallbladder volvulus is an uncommon disease caused by torsion of the gallbladder around its mesentery along the axis of the cystic duct and artery, ultimately leading to gallbladder ischemia and obstruction of biliary drainage. The etiology of the condition is unknown; however, hypothesized contributory factors include anatomical abnormalities including a long gallbladder mesentery allowing it to float freely from the liver bed and easily twist upon itself. Volvulus can be seen more commonly in older females and is likely due to loss of visceral fat with aging. This diagnosis was first discovered in 1898 by an American surgeon Wendel, who referred to the condition as "floating gallbladder." Gallbladder volvulus only accounts for 1 out of 365,000 cases of gallbladder disease. Thus, although rare, laparoscopic cholecystectomies are one of the most common surgical procedures performed in the United States and it is important for surgeons to familiarize themselves with the condition due to its severe complications.
Here, we present a case of a 77-year-old female who presented for right upper quadrant pain, weight loss and nausea associated with eating. CT scan and ultrasound demonstrated a distended hydropic-appearing gallbladder with pericholecystic fluid and wall thickening without evidence of gallstones. Upon laparoscopic inspection, the gallbladder was necrotic, gangrenous and mostly detached from the liver bed as a result of twisting upon its mesenteric stalk. The mesentery was unable to be detorsed because the gallbladder was enlarged and necrotic in appearance with only its neck clearly identifiable. A laparoscopic subtotal reconstituting cholecystectomy was able to be performed without postoperative complication.
In conclusion, gallbladder volvulus is a rare presentation of acute right upper quadrant abdominal pain. The patient’s clinical presentation and imaging can mimic those seen in patients with biliary colic or acute cholecystitis. Pre-operative diagnosis is rare; however, a high suspicion should prompt urgent surgical intervention in order to prevent necrosis and possible perforation. Ideally, the surgeon should attempt to return the gallbladder to its anatomic position. However, due to the severe distension and the necrotic presentation usually seen with this disease, obtaining the critical view of safety can present as an intraoperative challenge. Intraoperative decision making plays a crucial role in this condition in order to proceed with the procedure safely and without increasing morbidity and mortality.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93541
Program Number: P204
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster