Acute torsion of the gall bladder.

An 89 year old man presented to the emergency department with a two days history of acute onset abdominal pain in the upper right quadrant, with fever, vomiting and malaise. His medical history included peptic ulcer disease and tobacco abuse. There was no significant relevant past surgical history. He was dehydrated at presentation with the following vital signs: HR86 b/min, BP-100/50 mmHg, T-38.5°C. Focused abdominal examination demonstrated tenderness to palpation in the right upper quadrant, and a positive Murphy’s sign. Laboratory blood tests revealed a leukocytosis of 22.7×103/L, C-reactive protein of 48 mg/L and normal kidney and liver function tests. Abdominal ultrasonography (Figure 1) and computed tomography (CT) scan (Figure 2) showed a clearly enlarged gallbladder with a thickened wall of 7 mm, with fluid sub-hepatically. They demonstrated no gallstone. Free air within the gallbladder wall was not seen. He was admitted to our hospital with the diagnosis of acute cholecystitis. After resuscitation emergency laparotomy through a midline incision was performed. On entering the abdominal cavity, a gangrenous distended gallbladder with omentum adhesed to it circumferentially was immediately noted (Figure 3). It was rotated more than 360 degrees anticlockwise around its mesentery. The gallbladder torsion was reduced and a cholecystectomy was then performed in the standard fashion, with placement of a drain in the gallbladder fossa. No gallbladder stones were found in the specimen. Histology revealed transmural necrosis consistent with volvulus. His post-operative course was unremarkable and he was discharged on post-operative day 3.