Gallbladder volvulus: clinical presentation mimicking acute appendicitis of the elderly

Vólvulo de vesícula biliar. Presentación clínica como apendicitis aguda del anciano

Key words: Gollbladder volvulus. Acute cholecistitis. Acute abdomen.

Palabras clave: Vólvulo de vesícula. Colecistitis aguda. Abdomen agudo.

Dear Editor,

Gallbladder volvulus is a very uncommon event that is more frequently seen in elderly women (1-5). It is defined as the rotation of the gallbladder on its mesentery along the axis constituted by the cystic conduct and the cystic artery (3). Its presentation as an acute abdomen episode is exceptional (1-5). We report the case of a 95 year old man with suspected acute appendicitis in the context of an acute abdomen episode who was found to have a gallbladder volvulus during surgery.

Case Report

A 95 year old man previously healthy attended the emergency department referring a twenty four hour history of right iliac fossa pain which became progressively more intense. No other associated symptomatology.

The physical exam revealed a pronounced dorsal kyphosis. The abdomen appeared soft and tender with intense pain and peritonism in the right iliac fossa and right flank. Blood test showed leukocytosis (12.500/mm³) with neutrophilia (85%). CT scan of the abdomen demonstrated an intra abdominal collection in the right iliac fossa and right parietocolic space. The rest of the complimentary tests including blood chemistry, chest and abdomen X-ray were normal. With the suspected diagnosis of acute appendicitis the patient underwent an emergency medium, supra-and infra-umbilical laparotomy. The appendix was found to be normal at that time. Further examination during surgery revealed a gallbladder volvulus. Macroscopically the gallbladder appeared edematous, congestive and patchy necrotic (Fig. 1). It was done a detorsion of 180 degrees and subsequent cholecystectomy performed. The patient experienced an uneventful post-operative admission and could be discharged seven days after surgery. Histology was compatible with alitiasic acute cholecystitis.

Discussion

Gallbladder volvulus is an infrequent cause of acute abdomen. Nevertheless, an increasing number or reports describing this complication have been reported in the last decades along with an increase in life expectancy suggesting a relation between elderly and appearance of this condition (1-4). Other potential factors described to contribute to the appearance of this complication are lax and mobile vesicular mesentery, age related visceral ptosis, multiparity, congenital malformations, multiple lithiasis and kyphoscoliosis (1). All published cases report the finding of floating gallbladder due to a mobile mesentery.

Clinically it presents as an acute cholecystitis, usually a less aggressive and serious illness than gallbladder volvulus. A low index of suspicious due to its low frequency with the subsequent delay in diagnosis and treatment make of this disease a potential life threatening condition.

Radiology tests seem to be of limited value in this setting. Nonetheless, ultrasound remains as a useful tool in early diagnosis when describing a large floating gallbladder with thickened wall and multiple loops.

Juan Luis Rueda-Martínez, Pedro Cascales-Sánchez, Pablo Vázquez-Aragón,
Antonio Serafín Valero-Liñán and Antonio Prat-Calero
Unit of Gastrointestinal Surgery. Complejo Hospitalario
Universitario de Albacete. Albacete, Spain

References

1. Sancha Pérez AM, Martínez-Conde López AE, Romeo Ramírez JA, Olivares Galdeano U, Gómez de Carrero Foncea JC, Echavarri Iñigo J. Volvulus of the gallbladder. Descripcion of a case. Gastroenterol Hepatol 1998;21:133-5.         [ Links ]

2. Coquaz S, Bruant P, Regenet N, Lermite E, Pessaux P, Arnaud JP. Gallbladder volvulus: two cases report. Ann Chir 2005;130:252-3.         [ Links ]

3. Tarhan OR, Barut I, Dinelek H. Gallbladder volvulus: review of the literature and report of a case. Turk J Gastroenterol 2006;17:209-11.         [ Links ]

4. Malherbe V, Dandrifosse AC, Detrembleur N, Denoel A. Torsion of the gallbladder: two case reports. Acta Chir Belg 2008;108:130-2.         [ Links ]

5. Kimura T, Yonekura T, Yamauchi K, Kosumi T, Sasaki T, Kamiyama M. Laparoscopic treatment of gallbladder volvulus: a pediatric case report and literature review. J Laparoendosc Adv Surg Tech A 2008; 18:330-4.         [ Links ]