You are in: eMedicine Specialties > General Surgery > Abdomen Gallbladder VolvulusArticle Last Updated: Sep 5, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Alan A Saber, MD, Chief, Minimally Invasive Surgery and Bariatric Surgery, Department of Surgery, Assistant Professor, Michigan State University Alan A Saber is a member of the following medical societies: American College of Surgeons, American Society for Bariatric Surgery, and American Society for Gastrointestinal Endoscopy Coauthor(s): Raul J Rosenthal, MD, Program Director of Minimally Invasive Surgery, Cleveland Clinic Florida; Assistant Professor, Department of Surgery, Florida Atlantic University; Danny Rosin, MD, Instructor, Department of General Surgery and Transplantation, Sheba Medical Center, Tel Hashomer, Israel Editors: Oscar Joe Hines, MD, Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia; Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy; John Geibel, MD, DSc, MA, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital Author and Editor Disclosure Synonyms and related keywords: torsion of the gallbladder, gallbladder torsion, mesentery, peristalsis, kyphoscoliosis, visceroptosis, tortuous atherosclerotic cystic artery, gallbladder thumbprinting, acute cholecystitis INTRODUCTIONSection 2 of 11
  Torsion of the gallbladder is a condition in which the organ twists on its long axis to an extent that its vascular supply is compromised. ProblemGallbladder volvulus was recognized almost 100 years ago. This condition remains a rare entity that seldom is diagnosed preoperatively. It is encountered most frequently in patients who are fragile and elderly. A delay in the diagnosis and treatment may result in life-threatening consequences. FrequencySince 1898, when Wendell first described gallbladder volvulus, 300 cases of gallbladder torsion have been reported. Recently, the incidence appears to have increased. The reason for this rise possibly is due to an increase in life expectancy. Of patients with gallbladder volvulus, 84% are elderly women. The peak incidence occurs in persons aged 65-75 years. EtiologyTwo anatomic variants of the gallbladder might undergo torsion. In one type, the gallbladder has a mesentery that is prone to torsion. 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 violent movements, including intense peristalsis of the neighboring organs, kyphoscoliosis of the spine, visceroptosis, and tortuous atherosclerotic cystic artery. The role of gallstones is debatable. Approximately 20-33% of patients with torsion have gallstones. Intense peristalsis by the stomach or the duodenum has been implicated in clockwise rotation, whereas the transverse colon is implicated in counterclockwise rotation. PathophysiologyTorsion of the gallbladder can be complete (ie, >180°) or incomplete (ie, <180°). 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. ClinicalThe clinical features can be grouped into 3 triads. The characteristics of the first triad consist of patients who are elderly, thin, and have deformed spines. The second triad is characterized by patients with right upper quadrant abdominal pain, early onset of vomiting, and a short history of symptoms. The third triad of signs consists of an abdominal mass, a lack of toxemia or jaundice, and discrepancies in pulse and temperature. Incomplete torsion usually is associated with recurrent episodes of slowly progressive pain, while complete torsion has an acute presentation. INDICATIONSSection 3 of 11
Torsion of the gallbladder should be treated by prompt cholecystectomy. RELEVANT ANATOMYSection 4 of 11
See Etiology. CONTRAINDICATIONSSection 5 of 11
Operative intervention is necessary to avoid a fatal outcome due to nonresected gallbladder volvulus. WORKUPSection 6 of 11
Lab Studies
Imaging Studies
Histologic FindingsFindings consistent with an acute hemorrhagic infarct are present. TREATMENTSection 7 of 11
Surgical therapyTorsion of the gallbladder should be treated by prompt cholecystectomy. Laparoscopic cholecystectomy is both feasible and safe in the treatment of gallbladder volvulus, allowing a faster patient recovery and a shorter hospital stay than open cholecystectomy. Preoperative detailsPreoperative diagnosis of gallbladder torsion usually is difficult. The most important differential diagnosis is acute cholecystitis. Advances in diagnostic imaging, chiefly abdominal US and CT scan, have been accompanied by increases in the number of cases reported to have been diagnosed preoperatively. Intraoperative detailsEvacuation of the gallbladder may be necessary to allow grasping with instruments. Detorsion of the gallbladder must be accomplished first. This avoids tenting and possible injury of the common bile duct. COMPLICATIONSSection 8 of 11
Injury of the common bile duct may occur during ligation of the cystic duct. The twisted gallbladder can tent the common bile duct, making it vulnerable to injury. OUTCOME AND PROGNOSISSection 9 of 11
When gallbladder torsion is diagnosed and treated early, morbidity and mortality rates reportedly are low. Delayed or missed diagnosis and treatment increase the patient mortality rate. FUTURE AND CONTROVERSIESSection 10 of 11
Increased use of imaging studies and laparoscopy will lead to early diagnosis and treatment of gallbladder volvulus. REFERENCESSection 11 of 11
Article Last Updated: Sep 5, 2007 |
