Acute gallbladder torsion: computed tomography and magnetic resonance imaging findings

Abstract

An 88‐year‐old female presented to emergency with a 3‐h history of severe, colicky epigastric and right upper quadrant pain radiating to the lower abdomen with associated nausea and vomiting. Initial observations revealed normal temperature and heart rate but hypertension with a systolic blood pressure of 180 mmHg. On examination the abdomen was soft and non‐distended with a tender, palpable mass in the right upper quadrant. Blood tests showed an elevated white cell count (14.2 × 109/L), and mildly deranged liver function tests with a normal bilirubin (18 μmol/L). Abdominal computed tomography scanning was requested, which revealed a markedly distended gallbladder with moderate pericholecystic fluid but no cholelithiasis. The intra‐ and extrahepatic biliary tree was dilated with the common bile duct measuring 10 mm in the pancreatic head but no obstructing lesion or stone was visible. Initial management was commenced, including analgesia, intravenous fluid resuscitation and broad spectrum intravenous antibiotics. Due to the imaging findings suggesting distal biliary tree obstruction of unclear aetiology, contrast enhanced magnetic resonance imaging (MRI) scanning was performed prior to cholecystectomy. MRI findings consisted of a distended and thick‐walled gallbladder with reduced signal along the posterior gallbladder wall and a 2‐mm calculus at the gallbladder neck. Gallbladder orientation was abnormal with the fundus situated infero‐medial to Hartmann's pouch. Biliary tree and pancreatic ductal dilatation to the ampullary level was again observed (13 mm proximal common bile duct [CBD]) but no obstructing common bile duct calculus or peri‐ampullary mass was identified (Fig. 1). At laparoscopic cholecystectomy a gallbladder torsion was observed with associated haemorrhagic necrosis but no gallbladder perforation (Fig. 2). Following decompression and de‐torsion, surgery proceeded uneventfully, histological examination was consistent with acute gangrenous cholecystitis with no cholelithiasis. The patient recovered well from surgery and was discharged home on post‐operative day 2.