76 year old man with O2 dependent COPD, chronic afib on Coumadin (PT 30 and INR 3.0), new ST changes on EKG comes in dehydrated (BUN 54/Cr1.7) with abdominal pain for 1 week but worse in last 2 days starting in upper abdomen and associated with lack of bowel movement in several days. Appetite okay (had ham and eggs Monday morning) unti late in the day. His doctor thought he was obstiipated , admitted him, ordered GI consult and CT scan. GI doctor called me to evaluate him.
Laboratory and diagnostic studies
WBC was 13.7 and later after admission 8K. When I saw him, he was definitely distended but no obvious peritoneal signs. I reviewed CT scan that was done with 2 radiologists. Other than air and stool throughout colon, there was a grossly distended gallbladder with a thickened wall. I elected to hydrate him, reverse his anticoagulation over night and consider percutaneous drainage of the gallbladder in the morning. This morning when I saw him, he was in much more pain, he was complaining of more diffuse pain, his WBC was 3K and he had a definite acute surgical abdomen.
Treatment of gallbladder torsion
At ex lap, I found a torsion of the gallbladder. In fact the gallbladder was torsed 5 times on the cystic duct and artery. After completing the rest of the exploration, I removed his gallbladder which had very little attachment to the liver bed and was definitely infarcted. The patient is still extremely ill in ICU intubated. At this point his pulmonary problems will be our most difficult problem.
I did a medline search and found many case reports about this abnormality. It appears that although not common, it has been described in 13 years olds but is mostly found in older people, mostly women. The diagnosis is usually found at ssurgery. There are reports of findings that would alert one to the diagnosis by ultrasound ( not done in this case). Earlier operations are better.
Has anyone seen a case of gallbladder torsion before? Would anyone have operated sooner?