Gallbladder volvulus

Gallbladder volvulus Microchapters
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Epidemiology and Demographics
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aditya Govindavarjhulla, M.B.B.S. [2]

Synonyms and keywords: Torsion of gallbladder

Overview

Volvulus is twisting of a non solid organ around its mesentric axis. Gallbladder volvullus is twisting or rotation of gall bladder along the axis of cystic duct and vascular pedicle(cystic artery).

Historical Perspective

It was first described by Wendal in 1898.

Pathophysiology

Torsion of gall bladder leads to occlusion of cystic duct and artery. This torsion can be complete (180^o - 360^o) or incomplete(< 180^o). Incomplete torsion causes obstruction to bile duct and vascular supply may be spared. In complete obstruction both are compromised. This occlusion leads to increase in bile in the lumen and decreased flow of blood to the organ. Increased pressure in the lumen with ischemia leads to acute inflammation causing surgical emergency.

Gross Pathology

• Enlarged and distended gallbladder.
• Torsion along the long axis of the peduncle.
• Thick edematous wall with mucosal congestion.

Microscopic Pathology

• Extensive necrosis of the wall.
• Findings may be similar to gangrenous cholecystitis due to severe ischemia.
• The GB wall shows almost complete coagulation necrosis with intramural hemorrhages.
• A thin layer of degenerated collagen fiber, derived from the mucosa and proper muscle, may be seen along the inner side, and a thin subserosal connective tissue layer may seen along the outermost side.

Causes

Volvulus of gallbladder is known to be caused due to

• Inherent causes
  • Floating gallbladder
• Acquired causes
  • Splanchnoptosis
  • Senile humpback
• Physical causes
  • Sudden changes of intraperitoneal pressure
  • Sudden changes of body position
  • Hyperperistalsis of organs near the gallbladder
  • Trauma to the abdomen

Differentiating Gallbladder Volvulus from other Diseases

• Careful evaluation is important to rule out other causes jaundice argue against the diagnosis
  • Absence of toxemia
  • Poor response to antibiotic therapy
  • Ultrasound or other imaging studies help in differentiating gallbladder volvulus from other causes.

Epidemiology and Demographics

Over 500 cases have been documented since its description in 1898.

Age

• Few cases are reported in pediatric population.
• 85% of the cases are reported in 60 - 80 age group.

Gender

• There is a female preponderance for this condition.
• Female to male ratio is 3:1.

Risk Factors

Risk factors for gallbladder volvulus include

• Hyperperistalsis
• Scoliosis
• Weight loss
• Multiparity
• Constipation

The role of cholelithiasis as a risk factor is uncertain.

Natural History, Complications and Prognosis

Complications

• Acute perforation
• Bilious peritonitis
• Bowel adhesion
• Gallbladder necrosis
• Gangrenous cholecystitis
• Sepsis

Prognosis

• It has favorable a prognosis due to early diagnosis and prompt treatment.
• With immediate surgery the mortality rate is less than 5%.

Diagnosis

Presentation of gallbladder volvulus is very non -specific. It is tough to diagnose based upon history and symptoms alone as patients presents with acute pain abdomen with or without vomiting. At times there may be a tender mobile mass palpated suggestive of floating gallbladder.

Lau et al grouped clinical features into three triads

• Triad of patient characteristics
  • Thin patient
  • Old patient with chronic chest disease
  • Patient with deformed spine
• Triad of symptoms
  • Typical abdominal pain
  • Early onset of vomiting
  • A short history of symptoms
• Triad of physical signs
  • An abdominal mass,
  • Lack of toxaemia or jaundice
  • A discrepancy in the pulse and temperature.

Laboratory Findings

• Laboratory investigations are largely unhelpful for diagnosis of gallbladder volvulus.
• Findings of ongoing inflammatory process are noticed.
• Elevated white blood counts, raise in C- reactive protein are noticed.
• Liver enzymes are usually normal.

CT

Kitgawa H et al has provided a criteria based upon CT findings for the diagnosis of gallbladder volvulus.

• The criteria is
  • Collection of fluid between the gallbladder and the gallbladder fossa of the liver.
  • A horizontal positioning of the long axis of the gallbladder.
  • A well-enhanced cystic duct located on the right side of the gallbladder
  • Marked edema with thickening of the wall(signs of inflammation).

Whirl Sign

The contrast-enhanced multidetector computed tomography (MDCT) scan clearly shows twisted pedicle of the cystic duct and gallbladder mesentery on the right side of the gallbladder. This is called "whirl sign," and is a definitive diagnosis of gallbladder torsion.

MRI

MRI shows

• Marked wall thickening
• High signal intensities of this thickening on T1- and T2-weighted images.
• A thin hypointense rim will be noticed along the inner surface of the thickened wall on the T2-weighted image

MR cholangiopancreatography (MRCP) shows

• A stretched cystic duct
• Findings similar to those with T2-weighted images.
• Discontinuation between the Gall bladder body and the cystic duct.

Ultrasound

Yeh et al have suggested few findings on ultrasound which are suggestive of torsion of gallbladder.

• Sign of a floating gallbladder almost the entire gallbladder is located below the liver and is not in contact with the liver.
• Sign of twisted pedicle, pedicle represents the combined cystic duct, cystic artery, and vein as well as mesentery.
• Signs of an inflamed gallbladder( gallbladder wall is diffusely thickened and hypoechoic).

The thickening of the gallbladder wall may not be uniform. The focal thinning (or normal thickness) at the fundal region may indicate possible perforation or impending perforation inthis area. Localized fluid collections around the gallbladder is suggestive complication.

• Evaluation of blood flow in cystic artery may be done with color doppler.