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Journal of Radiology Case Reports

Gallbladder torsion resulting in gangrenous cholecystitis within a parastomal hernia: Findings on unenhanced CT

Case Report

Jessica K. Rosenblum1*, R. Joshua Dym1, Norman Sas2, Alla M. Rozenblit1

Radiology Case. 2013 Dec; 7(12):21-25 :: DOI: 10.3941/jrcr.v7i12.1518

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1. Department of Radiology, Montefiore Medical Center, Bronx, NY, USA
2. Department of Surgery, Montefiore Medical Center, Bronx, NY, USA

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  ABSTRACT
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Gallbladder torsion is a rare cause of acute gangrenous cholecystitis; its occurrence within an abdominal hernia has not been previously reported. We present such a case occurring within a parastomal hernia and imaged with unenhanced CT.








  CASE REPORT
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A 76 year-old man presented to the emergency room with two days of abdominal pain. He denied fever, chills, nausea, vomiting, constipation, diarrhea, and blood in the stool. His prior medical history included colectomy and ileostomy for ulcerative colitis, bilateral inguinal hernia repair, and an episode of upper gastrointestinal bleeding 42 years, 18 years and one year prior to the admission, respectively.

Physical exam revealed that the patient was afebrile, with a blood pressure of 100/50 and heart rate of 72. A large non-reducible hernia was palpated in the area of his right lower quadrant ileostomy, and the patient reported tenderness at the inferolateral aspect of the hernia. There was no change in ileostomy output. Laboratory values were significant for a white count of 18.9 k/mL (normal 4.8-10.8), with a granulocyte fraction of 89% (normal 40-70%), and a creatinine/BUN of 1.7/9.2 ( normal 0.5-1.5/8-26 )

CT of the abdomen and pelvis was obtained; this was performed without intravenous contrast administration due to the patient`s impaired renal function. The CT examination showed a large parastomal hernia at the site of the right lower quadrant ileostomy. The hernia contained multiple non-dilated small bowel loops as well as a markedly distended, thick-walled gallbladder; mural and luminal gas as well as multiple radiopaque gallstones were noted within the gallbladder (Fig. 1 Preview this figure

Figure 1: Computed Tomography
76 year-old man with gallbladder torsion in a parastomal hernia. Findings: Markedly distended and thick-walled gallbladder with gallstones, intramural and intraluminal gas (arrows) in a right lower quadrant parastomal hernia. The gallbladder neck is elongated and deformed; however, the twist is not clearly appreciated due to lack of intravenous contrast. Technique: Reconstructed axial (a), sagittal (b) and coronal (c) unenhanced CT with oral contrast, mAs 181, kV 120, slice thickness 5 mm.
). The gallbladder neck appeared elongated and deformed, which was attributed to the abnormal orientation and ectopic location of the gallbladder. At this time, diagnostic considerations included emphysematous or gangrenous cholecystitis, primary gallbladder ischemia due to incarceration within the hernia, and possible fistulous communication with the gastrointestinal tract. The latter was considered unlikely due to an unremarkable appearance of the adjacent bowel and lack of pneumobilia.

The patient was taken to the operating room, where a laparoscopic procedure was initiated with the goals of reducing the herniated gallbladder and small bowel loops and performing a cholecystectomy. Due to technical difficulties, including the fact that the narrow neck of the hernia prevented reduction of the hernia contents, the laparoscopic procedure was converted to an open surgery. Within the hernia, the gallbladder was found to be markedly distended and necrotic; the adjacent small bowel loops were edematous. The gallbladder was delivered with difficulty from the hernia sac, and was noted to have undergone a 360 degree twist (Fig. 2 Preview this figure
Figure 2: Macroscopic pathology
76 year-old man with gallbladder torsion in a parastomal hernia. Findings: Markedly distended gallbladder with a discolored necrotic appearing surface (short arrow). The 360 degree twist of the gallbladder neck (long arrow). Technique: Intraoperative photographs
), with patchy areas of necrosis evident in the wall.

Pathologic inspection demonstrated the gallbladder to be markedly edematous with hemorrhagic changes, mural necrosis and acute suppurative inflammation.

The patient had an uneventful postoperative period and was discharged home on the fifth postoperative day.

  DISCUSSION
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Gallbladder torsion (or volvulus) is a rare condition, with approximately 400 cases reported in the literature since originally described by Wendel in 1898 [1,2]. This condition occurs three times more frequently in women than in men [3]. It is believed that gallbladder torsion is becoming more common with increasing longevity, as the mesentery elongates with age, resulting in visceroptosis [4]. Incomplete torsion occurs when the twist is less than 180 degrees; greater than 180 degrees of twisting is considered complete torsion [2]. Gallbladder torsion is diagnosed preoperatively in only 10% of cases [5]. For unclear reasons, this condition is more frequently reported in the Asian literature. Torsion of the gallbladder neck typically results in vascular compromise and mural necrosis [3,6]. The gallbladder can occasionally be found within an abdominal hernia [7], and several cases of acute cholecystitis within a hernia have been reported [8,9,10]. No case of gallbladder torsion in an abdominal hernia has previously been described in the English language literature.

Clinical and Imaging Findings
Symptoms of gallbladder torsion may be intermittent secondary to torsion-detorsion phenomenon. The clinical presentation is otherwise similar to that of acute cholecystitis, with symptoms including right upper quadrant pain and often fever, nausea and vomiting. Depending on the degree of vascular compromise and associated infection, the radiographic presentation may differ, with the appearance often overlapping with that of acute cholecystitis [11]. Nakao et al. describe the largest surgical series (245 patients) of gallbladder torsion dating back to 1932, with a small minority of the cases undergoing cross-sectional imaging, primarily ultrasonography. On ultrasound, a freely mobile gallbladder with a thickened wall is often noted. Sonographic features most suggestive of gallbladder torsion include a horizontal lie of the gallbladder with a cystic duct located to the right of the gallbladder, and a conical structure at the gallbladder neck representing the twisted pedicle [6, 12]. Interestingly, gallstones are present in only 60% of cases of torsion, less frequently than in typical acute cholecystitis. On Doppler sonography, the wall of a torsed gallbladder may fail to demonstrate flow, while many cases of acute cholecystitis show gallbladder wall hyperemia [3]. On CT, Chou et al. report a V-shaped configuration of the hepatic ducts, pointed toward the torsed gallbladder. If contrast is administered, poor gallbladder wall enhancement may be evident, and a twisted cystic artery with a "whirl sign" may be seen [6]. When evaluated with MRI, high signal on T1-weighted images in the gallbladder wall suggests hemorrhagic change in the wall that may be seen with torsion and/or a more advanced case of cholecystitis, such as gangrenous cholecystitis [11]. MRCP may show a tapered cystic duct without clear connection to the gallbladder [13].

Acute cholecystitis occurring within various types of abdominal wall hernias has been described in several case reports. The locations included Spigelian, inguinal, and parastomal hernias [8,9,10]. In the reported cases, the etiology of acute cholecystitis was a calculus obstructing the gallbladder neck or ischemia secondary to incarceration by the narrow neck of the hernia. The authors of these case reports did not describe the imaging findings in these cases.

In our case, the non-contrast CT showed that a markedly distended, thick-walled gallbladder with mural and luminal gas and containing stones was located within a parastomal hernia. There was distortion at the gallbladder neck, which at the time was believed to be a consequence of the gallbladder herniation. Furthermore, due to non-contrast technique, the actual twist could not be identified. Although wall thickening of a distended gallbladder is often seen with uncomplicated acute cholecystitis due to cystic duct obstruction, the presence of mural and luminal gas suggests a more advanced process, usually seen with emphysematous or gangrenous cholecystitis; resulting from gas-producing infection in the former and inflammation-induced focal ischemia in the latter [14]. In our case, gangrenous changes in the gallbladder wall occurred because of torsion of its neck with secondary suppuration. We believe that the entrapment of the gallbladder within the hernia made it less likely for the gallbladder to untwist once torsion occurred.

Treatment and Prognosis
Gallbladder torsion is treated with emergent laparoscopy, surgical detorsion, and cholecystectomy. In complex cases, such as our case with the gallbladder within a hernia, open surgery may be required. The prognosis is similar to other types of complicated cholecystitis.

Differential Diagnosis
The most common findings of gallbladder torsion, mural thickening and pericholecystic fluid, are much more commonly associated with acute calculous or acalculous cholecystitis. Additionally, these imaging findings are nonspecific and may be present in the setting of cardiac or hepatic disease. A distended, thick-walled gallbladder with cholelithiasis and mural and luminal gas is highly suspicious for emphysematous or gangrenous cholecystitis. When such a gallbladder is located within a hernia along with mildly thickened small bowel, additional considerations include primary gallbladder ischemia due to incarcerated hernia, as well as possible cholecystoenteric fistula.

  TEACHING POINT
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Albeit rare, gallbladder torsion should be considered when imaging findings of complicated cholecystitis are present, if there is an abnormal lie of the gallbladder, or when a distended, inflamed gallbladder is seen within a hernia. Further evaluation of the pedicle with Duplex sonography or contrast enhanced CT or MRI may be helpful in arriving at the correct pre-operative diagnosis, if a patient`s condition permits.








  FIGURES
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Display figure 1 in original size

Figure 1: 76 year-old man with gallbladder torsion in a parastomal hernia. Findings: Markedly distended and thick-walled gallbladder with gallstones, intramural and intraluminal gas (arrows) in a right lower quadrant parastomal hernia. The gallbladder neck is elongated and deformed; however, the twist is not clearly appreciated due to lack of intravenous contrast. Technique: Reconstructed axial (a), sagittal (b) and coronal (c) unenhanced CT with oral contrast, mAs 181, kV 120, slice thickness 5 mm.

Figure 1: Computed Tomography (Open in original size)
76 year-old man with gallbladder torsion in a parastomal hernia. Findings: Markedly distended and thick-walled gallbladder with gallstones, intramural and intraluminal gas (arrows) in a right lower quadrant parastomal hernia. The gallbladder neck is elongated and deformed; however, the twist is not clearly appreciated due to lack of intravenous contrast. Technique: Reconstructed axial (a), sagittal (b) and coronal (c) unenhanced CT with oral contrast, mAs 181, kV 120, slice thickness 5 mm.

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Display figure 2 in original size
Figure 2: 76 year-old man with gallbladder torsion in a parastomal hernia. Findings: Markedly distended gallbladder with a discolored necrotic appearing surface (short arrow). The 360 degree twist of the gallbladder neck (long arrow). Technique: Intraoperative photographs

Figure 2: Macroscopic pathology (Open in original size)
76 year-old man with gallbladder torsion in a parastomal hernia. Findings: Markedly distended gallbladder with a discolored necrotic appearing surface (short arrow). The 360 degree twist of the gallbladder neck (long arrow). Technique: Intraoperative photographs

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Display figure 3 in original size
Figure 3: Summary table of the key aspects and imaging findings associated with gallbladder torsion

Figure 3: Table (Open in original size)
Summary table of the key aspects and imaging findings associated with gallbladder torsion

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Display figure 4 in original size
Figure 4: Differential diagnosis table for gallbladder torsion. The differential diagnosis for gallbladder torsion includes acute cholecystitis and gangrenous/emphysematous cholecystitis.

Figure 4: Table (Open in original size)
Differential diagnosis table for gallbladder torsion. The differential diagnosis for gallbladder torsion includes acute cholecystitis and gangrenous/emphysematous cholecystitis.

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  REFERENCES
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1. Wendel AV. A case of floating gallbladder and kidney complicated by cholelithiasis with perforation of the gallbladder. Ann Surg 1898; 27:199 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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2. Lemonick DM, Garvin R, Semins H. Torsion of the gallbladder: a rare cause of acute cholecystitis. J Emerg Med 2006; 30(4):397-401 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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3. Nakao A, Matsuda T, Funabiki S.. Gallbladder torsion: case report and review of 245 cases reported in the Japanese literature. J Hepatobiliary Pancreat Surg 1999; 6(4): 418-421 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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4. McHenry CR, Byrne MP. Gallbladder volvulus in the elderly. An emergent surgical disease J Am Geriatr Soc Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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5. Hinoshita E, Nishizaki T, Wakasugi K. Pre-operative imaging can diagnose torsion of the gallbladder: report of a case. Hepatogastroenterology 1999; 46:2212-2215 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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6. Chou CT, Chen RC, Yang AD, Wu HK. Gallbladder torsion: preoperative diagnosis by MDCT. Abdom Imaging 2007; 32:657-659 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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7. Sirikci A, Bayram M, Kervancioglu R. Incisional hernia of a normal gallbladder; sonographic and CT demonstration. Eur J Radiol 2002; 41:57-59 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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8. Goldman G, Rafael AJ, Hanoch K. Acute acalculous cholecystitis due to an incarceratedepigastric hernia. Postgrad Med J 1985;61:1017-8 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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9. Garcia RM, Brody F, Miller J, Ponsky TA. Parastomal herniation of the gallbladder. Hernia 2005; 9: 397-399 Get full text
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10. St Peter SD, Heppell J. Incarcerated gallbladder in a parastomal hernia. J Can Chir 2005; 48: 46 Get full text
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11. Aibe H, Honda H, Kuroiwa T. Gallbladder torsion: case report. Abdom Imaging 2002; 27:51-53 Get full text
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12. Quinn SF, Fazzio F, Jones E. Torsion of the gallbladder: findings on CT and sonography and role of percutaneous cholecystostomy. AJR Am J Roentgenol 1987; 148:881-882 Get full text
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13. Usui M, Matsuda H, Suzuki H, Ogura Y. Preoperative diagnosis of gallbladder torsion by magnetic resonance cholangiopancreatography. Scand J Gastroenterol 2000; 35:218-222 Get full text
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14. Bennett GL, Rusinek H, Lisi V. CT findings in acute gangrenous cholecystitis. AJR Am J Roetgenol 2002; 178: 275-282 Get full text
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  ABBREVIATIONS
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CT = Computed Tomography








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