Gallbladder Volvulus
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Gallbladder volvulus, or torsion of the gallbladder, is a condition in which the organ twists on its long axis to the point where its vascular supply is compromised. [1, 2, 3] First recognized in the late 19th century, this condition remains a rare entity that seldom is diagnosed preoperatively. [4] It is encountered most frequently in patients who are fragile and elderly. A delay in the diagnosis and treatment of gallbladder volvulus may result in life-threatening consequences. [5]
Torsion of the gallbladder should be treated by means of prompt cholecystectomy. Operative intervention is necessary to avoid a fatal outcome due to nonresected gallbladder volvulus.
Torsion of the gallbladder can be complete (ie, >180º) or incomplete (ie, <180º). Complete torsion of a mobile gallbladder on its pedicle interferes with the blood supply to the organ, and if this condition is unrelieved, gangrene develops.
Two anatomic variants of the gallbladder might undergo torsion. In one type, the gallbladder has a mesentery that is prone to torsion. [6] In the other type, the mesentery supports only the cystic duct, allowing a completely peritonealized gallbladder to hang freely. Intermediate forms with a partial mesentery of the gallbladder and a mesentery of the cystic duct also are described.
In adults, a mesentery of the gallbladder can be acquired. The more frequent occurrence of torsion in elderly persons may be explained by the loss of fat and the atrophy of the tissues that may occur with advancing age, leaving the gallbladder hanging freely.
The precipitating factors for the final event of torsion have been cited as follows:
The role of gallstones is debatable. Approximately 20-33% of patients with torsion have gallstones.
Intense peristalsis of the stomach or the duodenum has been implicated in clockwise rotation, whereas the transverse colon is implicated in counterclockwise rotation.
Between 1898, when Wendell first described gallbladder volvulus, and the early 21st century, only about 300 cases of gallbladder torsion were reported. Since the first few years of the 21st century, however, the incidence appears to have increased, possibly because of an increase in life expectancy. As of 2014, about 500 cases had been reported. [4] The peak incidence of gallbladder volvulus occurs in persons aged 65-75 years; 84% of patients are elderly women.
Morbidity and mortality reportedly are low among cases of gallbladder torsion that have been diagnosed and treated early. [7] Delayed or missed diagnosis and treatment increase patient mortality.
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Dasyam AK, Koo J, Stahlfeld Miller M, Sell HW Jr, Tublin ME. The cystic duct knot sign: case report with description of a new ultrasound sign of gallbladder torsion. Emerg Radiol. 2015 Aug. 22 (4):445-7. [Medline].
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Goussous N, Maqsood H, Spiegler E, Kowdley GC, Cunningham SC. HIDA scan for functional gallbladder disorder: ensure that you know how the scan was done. Hepatobiliary Pancreat Dis Int. 2017 Apr. 16 (2):197-201. [Medline].
Fukuchi M, Nakazato K, Shoji H, Naitoh H, Kuwano H. Torsion of the gallbladder diagnosed by magnetic resonance cholangiopancreatography. Int Surg. 2012 Jul-Sep. 97(3):235-8. [Medline]. [Full Text].
Kitazume Y, Taura S, Nakaminato S, Noguchi O, Masaki Y, Kasahara I, et al. Diffusion-weighted magnetic resonance imaging to differentiate malignant from benign gallbladder disorders. Eur J Radiol. 2016 Apr. 85 (4):864-73. [Medline].
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Barrett M, Asbun HJ, Chien HL, Brunt LM, Telem DA. Bile duct injury and morbidity following cholecystectomy: a need for improvement. Surg Endosc. 2018 Apr. 32 (4):1683-1688. [Medline].
Alan A Saber, MD, MS, FACS, FASMBS Director of Bariatric and Metabolic Surgery, University Hospitals Case Medical Center; Surgical Director, Bariatric Surgery, Metabolic and Nutrition Center, University Hospitals Digestive Health Institute; Associate Professor of Surgery, Case Western Reserve University School of Medicine
Alan A Saber, MD, MS, FACS, FASMBS is a member of the following medical societies: American College of Surgeons, American Society for Gastrointestinal Endoscopy, American Society for Metabolic and Bariatric Surgery
Disclosure: Nothing to disclose.
Raul J Rosenthal, MD, FACS, FASMBS Professor of Surgery, Chairman, Section of Minimally Invasive Surgery and The Bariatric and Metabolic Institute, Program Director, Fellowship in Minimally Invasive Surgery, Herbert Wertheim School of Medicine, Florida International University
Raul J Rosenthal, MD, FACS, FASMBS is a member of the following medical societies: American College of Surgeons, American Society for Metabolic and Bariatric Surgery, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology
Disclosure: Received none from RFA Medical for director; Received none from MRC Biotec for director.
John Geibel, MD, DSc, MSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow
John Geibel, MD, DSc, MSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract
Disclosure: Nothing to disclose.
Oscar Joe Hines, MD Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine
Oscar Joe Hines, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Endocrine Surgeons, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.
The authors and editors of Medscape Drugs & Diseases wish to acknowledge Danny Rosin, MD, Instructor, Department of General Surgery and Transplantation, Sheba Medical Center, Tel Hashomer, Israel, for his previous association with this article.
Gallbladder Volvulus
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