Gall bladder torsion: a disease of the elderly

Abstract

We describe the case of a gall bladder torsion in an elderly female patient, which was discovered during laparoscopic exploration for presumed acute cholecystitis. The rising incidence of this relatively uncommon process can be attributed to increasing life expectancy. Gall bladder torsion typically manifests in septuagenarians and octogenarians of the female gender, as seen in the presented case. It is thought that local mesenteric redundancy predisposes to the development of mechanical organoaxial torsion along the gall bladder’s longitudinal axis involving the cystic duct and artery. Clinicians must have a high index of suspicion for gall bladder torsion, as a mimicker of acute cholecystitis, in the described patient demographic. Preoperative diagnosis is challenging with the vast majority of reported cases being diagnosed intraoperatively, and only five cases preoperatively. Prompt surgical intervention results in an overall mortality rate of approximately 5%, while a delay in diagnosis can lead to catastrophic patient outcomes.

Background

Gall bladder torsion is a rare but important differential diagnosis for elderly women who present with an acute surgical abdomen. It is imperative that clinicians remain cognisant of this disease, as prompt preoperative diagnosis leads to an improved prognosis. Our presentation of both radiological and intraoperative images will identify salient points in diagnosis, and treatment of this clinical entity for clinicians.

Case presentation

An 84-year-old Caucasian woman presented to the emergency department after waking with a sudden onset of severe and progressive right upper quadrant abdominal pain, exacerbated by movement and coughing. Associated phenomena included several episodes of vomiting and loose stools without haematochezia or mucus. Her surgical history was significant for an open appendicectomy 70 years ago and a long gamma nail for a femoral neck fracture in 2014. Her medical history only included controlled hypertension. Physical examination revealed a frail and febrile patient with normal vital signs. On focused abdominal examination there was a soft abdomen with a palpable mass in her right hypochondrium with a positive Murphy’s sign without overt peritonism.

Investigations

Laboratory investigations yielded a mild leucocytosis (13.3×10⁹/L) with neutrophilia and normal liver function. A CT scan was obtained prior to surgical consultation. The scan demonstrated a grossly dilated gall bladder with significant gall bladder wall thickening and pericholecystic fluid, as well as a slightly dilated common bile duct (maximum 9 mm), which tapers towards the ampulla with mild intrahepatic biliary tree dilation (figure 1).

Figure 1.

CT of the torted gall bladder.

Differential diagnosis

Patients who present to the emergency department with right upper quadrant abdominal pain and an acute surgical abdomen require consideration of a myriad of differential diagnoses including; acute cholecystitis, cholangitis, choledocholithiasis, peptic ulcer disease, gastritis, intussusception and nephrolithiasis.

Treatment

Antibiotics were commenced for suspected acute cholecystitis. Laparoscopy was performed and immediately revealed a gangrenous distended gall bladder. The gall bladder was decompressed with a Veress needle. On further careful dissection, it was discovered that the gall bladder had twisted 180° counterclockwise on its mesentery in the longitudinal axis of the cystic duct and artery, and the diagnosis of gall bladder torsion was made (figure 2). The intraoperative cholangiogram was unremarkable and a routine cholecystectomy was performed (figure 3). The specimen did not contain gallstones and histological examination revealed extensive haemorrhage and transmural necrosis consistent with torsion (figure 4).

Figure 2.

Laparoscopic view of the necrotic gall bladder and long torted mesentery.

Figure 3.

Intraoperative cholangiogram.

Figure 4.

Resected necrotic gall bladder.

Outcome and follow-up

The patient recovered well postoperatively and was discharged after 3 days of intravenous antibiotics.

Discussion

Gall bladder torsion is a rare entity affecting approximately 1 in 365 520 patients, and representing 0.1% of acute cholecystitis presentations.¹ There have been approximately 500 cases reported in the literature since it was first described by Wendell in 1898.^2–4 The vast majority of these cases are involving the geriatric population. More specifically, 85% of patients are over 60 years of age, with a peak incidence in 65–75 year-olds.¹ There is a predilection for females, with an occurrence ratio between women and men of 3:1.³ There have been multiple proposed mechanisms of gall bladder torsion described in the literature, but the exact aetiology remains unknown. Janakan et al propose two main anatomical variations of the gall bladder that might undergo torsion. The first type involves the gall bladder having its own mesentery that is prone to torsion. The second type involves the mesentery providing support only to the cystic duct thereby enabling an entirely peritoneal gall bladder to hang freely.⁵ However, intermediate forms with separate partial mesenteries of the gall bladder and cystic duct have also been described. All described hypotheses hold the presence of local mesenteric redundancy to be a prerequisite for the development of organoaxial torsion around its pedicle. The atrophy of adipose and local tissue that occurs in the elderly encourages free suspension of the gall bladder, which increases its susceptibility for rotational instability.⁶ Other risk factors include: visceroptosis, intense stomach and bowel peristalsis, malnutrition, blunt trauma and a tortuous atherosclerotic cystic artery.^{7 8} Some authors also implicate kyphoscoliosis as a risk factor, which can act as a fulcrum for torsion. The role of cholelithiasis is controversial, with approximately 20%–33% of patients with torsion having gallstones.^{1 7–9}

Preoperative diagnosis is extremely challenging and only 26% of cases have an accurate preoperative diagnosis.^{10 1 6} Nakao et al, in a review of the 245 cases in the Japanese literature, proposed that the constellation of acute abdominal pain, minimal episodes of fever or jaundice and poor response to antibiotics may help differentiate the diagnosis of torsion from cholecystitis, although with a relatively low accuracy.⁹ Furthermore, laboratory investigations are typically non-discriminating and often show a non-specific elevation in inflammatory markers with normal liver function tests, as demonstrated in the presented case.⁸ The classically described ultrasonographic finding is a large, ‘floating’ acalculous gall bladder. Ultrasound may also reveal a conical structure at gall bladder neck.¹ There have been several signs reported with the use of CT imaging, including: an enlarged gall bladder outside of the gall bladder fossa, severe pericholecystic fluid, prominent cystic artery to the right of the gall bladder and v-shaped distortion of extrahepatic ducts or a ‘Whirl sign’ with twisting of cystic artery.^{1 11–13} Nuclear medicine scans with use of hydroxyiminodiacetic acid have been reported to demonstrate more specific findings, such as a ‘bulls-eye’ sign, due to accumulated radioisotope.⁷ Alternatively, MRI has been reported to reveal the twisted cystic duct and may therefore provide the most specificity in preoperative diagnostics.^{7 14} Despite these advancements in imaging technology, there has been no improvement in the reported preoperative diagnosis rates.⁵ The gall bladder rotates on its mesentery in the axis of the cystic duct and artery, causing necrosis secondary to biliary and arterial obstruction.⁷ The authors implicate intense peristalsis of the stomach and duodenum with clockwise rotation, and the transverse colon with counterclockwise rotation. Rotation of 180° leads to necrosis, perforation and peritonitis.⁷ Gall bladder torsion has a 6% mortality rate due to biliary peritonitis from perforation.^{1 7} The vast majority of these mortalities occurred when the diagnosis was not made preoperatively.¹ Expedient operative intervention with correction of the torsion followed by removal of the gall bladder is the cornerstone of treatment of gall bladder torsion. A laparoscopic approach can be safely performed regardless of obtaining the correct diagnosis of torsion prior to surgery, as demonstrated in the described case.

Learning points.

• Gall bladder torsion is a rare surgical condition with a rising incidence, especially in elderly female patients.

• Despite recent technological advancement in medical imaging modalities, preoperative diagnosis remains very challenging due to their lack of sufficient sensitivity.

• Delayed diagnosis and surgical intervention is associated with increased morbidity and mortality rates.

• Clinicians must harbour a high index of suspicion of gall bladder torsion in this particular patient demographic to encourage prompt diagnosis and ensure that the patient undergoes urgent cholecystectomy.