Gallbladder torsion presenting as chest pain

Abstract

While acute torsion of the gallbladder is an uncommon pathology, as this case demonstrates, it can present with sudden onset of chest pain, and must be borne in mind as a differential diagnosis in this patient demographic if early recognition and definitive management are to be made possible.

Case history

An 88-year-old woman presented via accident and emergency with severe central chest pain, which settled partially with intravenous opiates. Her admission ECG showed no acute changes on the background of a paced rhythm, and full blood count indicated a leukocytosis of 13.2 × 10⁹/l. She was known to have ischaemic heart disease, having suffered a myocardial infarction 18 months earlier, necessitating a permanent pacemaker. Other past medical history included hypothyroidism, gastro-oesophageal reflux disease, diverticular disease, and a total abdominal hysterectomy and bilateral salpingo-oophorectomy for ovarian malignancy 5 years previously.

Having been assessed by the emergency department staff, the patient was commenced on an acute chest pain pathway, and transferred to the medical assessment unit. She was anticoagulated, and troponin measurement arranged for the next morning.

Overnight, she complained of increasing chest pain in association with vomiting, with radiation to her epigastrium, right upper quadrant, and through to her back. Assessment by the attending doctor noted her abdomen to be distended with right-sided abdominal tenderness. A plain abdominal radiograph showed features consistent with faecal loading, and she was commenced on laxatives. Due to progressive abdominal signs, a referral was made to the acute surgical team on-call for further assessment. She was found to be haemodynamically well compensated despite her paced rhythm, but she was exquisitely tender with right-sided rigidity and peritonism. The decision was made to undertake urgent exploratory laparotomy.

Findings at laparotomy were of a necrotic mass in the right upper quadrant (Fig. 1). On further inspection, a 360º torsion of the gallbladder around the cystic duct pedicle was identified (arrow, Fig. 2), which had led to acute infarction. Cholecystectomy was performed, and the patient had an uneventful postoperative recovery. She was deemed clinically stable enough for discharge to her own home on the 8th postoperative day.

Figure 1.

At laparotomy, a necrotic mass was found in the right upper quadrant.

Figure 2.

The point of gallbladder torsion was identified as the cystic pedicle (black arrow).

Discussion

Torsion of the gallbladder is an uncommon phenomenon, with around 500 cases reported in the literature. It has highest incidence in women in their seventh and eighth decades, and presents acutely with sudden onset of severe upper abdominal pain and vomiting, often without the classical signs of toxaemia. A tender right upper quadrant mass may be also be palpable.¹ The aetiology is not fully understood, but it has been suggested that a long gallbladder mesentery, and mobility of the fundus due to loss of elastic tissue in the elderly are contributory factors.² It is most commonly diagnosed intra-operatively, as imaging findings are relatively non-specific, but can include an anteriorly displaced ‘floating’, thick-walled, distended, and commonly acalculous gallbladder on ultrasound or computed tomography, accompanied by indicators of mural necrosis.³ If untreated, eventual sequelae are perforation with biliary peritonitis, and the subsequent systemic response which results in significant morbidity and mortality.⁴

Conclusions

As this case demonstrates, while acute torsion of the gallbladder is an uncommon pathology, it can present with sudden onset of chest pain, and must be borne in mind as a differential diagnosis in this patient demographic if early recognition and definitive management are to be made possible.