General information
The patient, male, 80 years old, was admitted to our department as an emergency patient with complaints of metastatic right lower abdominal pain for 4 days. T: 36.7℃; P: 92 beats/min; R: 20 beats/min; BP: 160/90mmHg, the patient had poor mental clarity, acute painful face, mild yellow sclera bilaterally, flat abdomen, no intestinal shape and peristaltic wave, liver and spleen were not reached, right abdomen and lower abdomen pressure pain was obvious, rebound pain was obvious, right abdominal muscle tension, Murphy’s sign (+), normal bowel sounds, no percussion pain in both kidney areas. The ultrasound showed: stone cholecystitis (multiple), dilated common bile duct (internal diameter 1.6 cm), and right kidney stone. Blood count: WBC: 19.1×109/L; N: 0.839; L: 0.088. Urine count: PRO +2. Initial diagnosis: periappendiceal abscess? ; acute attack of chronic calculous cholecystitis; dilated common bile duct; right kidney stone; hypertension. After admission to the hospital, a dissection was performed under continuous epidural anesthesia in an emergency. There were 33 cholesterol stones of different sizes, the largest being 1.5 cm in size and the rest being corn grain-like in size, and the stones were embedded in the neck of the gallbladder; the common bile duct was dilated, with an internal diameter of about 1.6 cm, and no stones were detected. During the operation, the gallbladder was removed, the common bile duct was opened for investigation and drainage by “T” tube, and the appendix was removed. Postoperative diagnosis: gallbladder torsion with gallbladder gangrene; multiple gallbladder stones; dilated common bile duct; secondary appendicitis; right kidney stone; hypertension. Postoperative anti-infective, supportive, symptomatic, and antihypertensive treatments were given, and he was discharged 12 days after surgery with improvement. Pathological diagnosis: gallbladder gangrene and acute simple appendicitis. Yu Jun, Department of Emergency Medicine, Lingwu People’s Hospital
Diagnosis
The clinical manifestation of gallbladder torsion is often sudden epigastric pain, often sharp pain in the right upper abdomen, (but older patients often have an unclear medical history), most patients have nausea and vomiting, few patients will have jaundice, but chills and fever are uncommon. The main findings are abdominal tenderness, rebound pain, muscle tension, Murphy’s sign (+), and in some patients, a right upper abdominal mass. The secondary investigations are mainly ultrasound, and the images may reveal a floating gallbladder, a distended or twisted stem, and an enlarged and inflamed gallbladder, and changes in the long axis of the gallbladder may be another important clue.
The diagnosis of gallbladder torsion is more difficult and can be easily confused with acute cholecystitis, acute pancreatitis, gastric perforation, and appendicitis, which can easily lead to misdiagnosis and mistreatment. In this case, due to the patient’s old age and unclear medical history, which also caused diagnostic difficulties, a dissection was performed and the diagnosis of gallbladder torsion was confirmed intraoperatively.
Treatment
Early surgery is the only treatment for gallbladder torsion.
Discussion
Gallbladder torsion is an uncommon condition, but it is a surgical emergency that is highly misdiagnosed in clinical practice. The histological presentation of the gallbladder in torsion is severe hemorrhage and necrosis, which is consistent with injury after torsion. Early diagnosis and surgery may reduce mortality.
The cause of gallbladder torsion is not known, but from what has been reported, it occurs mostly in the elderly with a male to female ratio of about 1:3. Normally, the gallbladder is pear-like and is located in the fossa of the gallbladder below the liver. The gallbladder is closely connected to the liver by connective tissue and is covered by the peritoneum to form the gallbladder tether, which is fixed in the right upper abdomen by virtue of these connections. In the elderly, due to the loss of tissue elasticity and liver atrophy, the gallbladder tether is relaxed, which increases the mobility of the gallbladder; or due to congenital abnormal development, the gallbladder is completely wrapped by the peritoneum, and a narrow tether is formed between the top of the gallbladder and the liver gallbladder fossa (this is called floating gallbladder, and some people call it tethered gallbladder), which increases the mobility of the gallbladder. Gallbladder torsion can be triggered by increased gastrointestinal peristalsis during feeding, by enlargement of the gallbladder due to stone impaction in calculous cholecystitis, or by sudden changes in body position. Gallbladder torsion not exceeding 180 degrees is incomplete type, at this time the gallbladder duct can be obstructed, but there is no blood flow obstruction, the disease develops slowly, the symptoms are mild, and sometimes it will reset naturally. The torsion is complete when it exceeds 180 degrees, where the cystic duct and the cystic artery are often twisted causing obstruction and bile accumulation in the gallbladder, along with hemorrhage, necrosis and perforation due to ischemia and hypoxia.
Although gallbladder torsion is an uncommon condition, without proper treatment, it can have high complications and mortality. ultrasound has an important place in the diagnosis. Surgical treatment is the only treatment option. The possibility of this disease should be noted in the differential diagnosis of acute abdominal pain.