Gallbladder Volvulus - Causes, Symptoms, Risk Factors, and Management

Introduction:

Diseases of the gallbladder are of various types. Gallstone is the most common of all the conditions. Rarely does the gallbladder become twisted, and it results in an uncommon condition called gallbladder volvulus. It can occur in any age group but more commonly occurs in older women, especially those who are above 70 years of age. Women are three times more likely to develop gallbladder volvulus than men.

Wendel, in the year 1898, first reported this condition as a ‘floating gallbladder.’ The occurrence of gallbladder volvulus is only one in 365,000 cases of gallstone among people. This condition does not have specific symptoms, which makes it difficult for the doctor to identify the condition. Imaging tests such as ultrasound, computed tomography (CT scan), and magnetic resonance imaging (MRI), are helpful diagnostic tools, and blood tests sometimes show increased levels of white blood cells (leukocytosis). The condition is treated through immediate surgery to remove the gallbladder (cholecystectomy).

What Is Gallbladder Volvulus?

It is a rare, uncommon condition of the gallbladder in which the gallbladder becomes twisted around its mesentery, a folded membrane that attaches the intestine to the stomach and holds it firmly in place. The condition is commonly seen in older adults, especially women.

What Causes Gallbladder Volvulus?

The proposed contributing factors are:

• Anatomical abnormality or deformity of the vascular pedicle.

• Abnormal shape of the mesentery, such as long mesentery. This allows the gallbladder to float. This results in the twisting of the gallbladder around the cystic duct.

• Involuntary movement of the muscles (peristalsis).

• Deformity of the spinal cord.

• Bended arteries or tortuous atherosclerotic cystic artery.

What Is the Pathophysiology of Gallbladder Volvulus?

When the gallbladder twists around its mesentery, it creates gallbladder torsion. When the blood supply to the gallbladder becomes compromised, it results in ischemia (reduced blood flow) and necrosis (death of the body tissue) of the tissues. This also obstructs the drainage or flow of the bile (a fluid or solution secreted and produced by the liver). This makes the gallbladder more susceptible to torsion with increasing age. The torsion can be complete or incomplete. If the rotation or twisting is more than 180 degrees, then it is called complete torsion. If the rotation or twisting is less than 180 degrees, then it is called incomplete torsion. The direction of the torsion can be clockwise or anticlockwise.

What Are the Symptoms of Gallbladder Volvulus?

The symptoms are not specific and are similar to acute infection. In general, the symptoms include:

• Sudden pain in the upper right side of the abdomen.

• Vomiting.

• Fever.

• Weight loss.

How to Diagnose Gallbladder Volvulus?

1. Patient’s History: The doctor will ask about the onset of symptoms, especially pain. The pain will be sudden and acute in the right upper quadrant of the abdomen.

2. Clinical Examination:The abdomen may be palpable. Upon palpation, the gallbladder may be found tender and swollen.

3. Blood Test:The blood test may show leukocytosis or an increased white blood cell count. The liver function test (LFT) is mostly normal and fails to identify the presence of gallbladder volvulus. Sometimes, C-reactive protein may show elevated levels.

4. Imaging Test: The commonly performed imaging tests to diagnose gallbladder volvulus are:

• Gallbladder volvulus ultrasound is the most helpful diagnostic tool. It may reveal the following:

  1. The thick, solid mass of the gallbladder wall represents gangrene (dead tissue due to lack of blood flow) and inflammation.

  2. Floating Gallbladder - the part of the gallbladder that does not stay in its original place, which is the bed of the liver.

  3. The cone shape of the gallbladder neck.

• Another imaging test that is usually performed is computed tomography. It shows:

  1. Floating gallbladder.

  2. Thick gallbladder wall or lining.

• Magnetic resonance imaging is performed to evaluate the necrosis of the gallbladder and twisting of the cystic duct.

• A hepatobiliary iminodiacetic acid (HIDA) scan reveals an accumulation of a chemical element or radioisotope in the gallbladder. It appears as a bull's eye in the image.

• Sometimes, endoscopy of the upper gastrointestinal tract shows distortion in the stomach appearance and/or image, shedding of the inner lining of mucosa, ulcers in the lining, and necrosis.

What Is the Gallbladder Volvulus Treatment?

If the patient appears with acute onset of symptoms and pain, then immediate surgical treatment is required. The appropriate surgical approach is cholecystectomy or removal of the gallbladder. An important step in the cholecystectomy must be the decompression and untwisting or derotation of the gallbladder. It can be done by open surgery or laparoscopic surgery (which involves a small incision with the help of a camera in the pelvis or abdomen). It is a minimally invasive surgical procedure to remove the gallbladder. There are two types of cholecystectomy methods:

• Open or Traditional Method: An incision of four to six inches is made on the upper right side of the abdomen, and the gallbladder is removed by the surgeon.

• Laparoscopic Method: Small multiple incisions are made on the upper right side of the abdomen, and a laparoscope (thin tube with a camera) is inserted. The surgeon visualizes the internal structures on a screen and removes the gallbladder. Laparoscopy is a less invasive method and has a shorter recovery time.

What Are the Complications of Gallbladder Volvulus Surgery?

• An Injury to biliary structures during surgery.

• A delay in the surgery may result in necrosis and infarction of the gallbladder.

• Biliary peritonitis - leakage of bile in the abdomen.

• Increased morbidity and mortality or death and disease rate.

What Is the Differential Diagnosis of Gallbladder Volvulus?

The symptoms of gallbladder volvulus may mimic the following conditions:

• Constipation is generally severe.

• Pseudo Obstruction - A rare condition in which the patient presents the symptoms of obstruction in the intestine but is not identified clinically.

• Sigmoid Diverticular Disease - Pushing of pouches outwardly from the walls of the colon.

• Ileosigmoid Knot - A rare condition in which the intestine is obstructed due to knotting.

Conclusion:

Gallbladder volvulus is a rare condition that requires immediate surgical intervention. It does not represent a specific group of symptoms and mimics other similar conditions and/or diseases of the abdomen such as constipation or obstruction. Cholecystectomy is the choice of treatment for this condition that can be done through open surgery or laparoscopic surgery. If treated early, then the prognosis of the condition is good. If the early treatment is not done, then it may lead to necrosis of the gallbladder and even increase the risk of death and other complications.