Twisted Gallbladder (Volvulus, Torsion) Causes, Symptoms, Surgery

The gallbladder is a hollow organ that stores bile, a fluid produced by the liver which contains a number of substances including wastes produced by the liver. It sits under the liver and empties bile out into the small intestine through the common bile duct. The gallbladder has a neck and its own duct, the cystic duct, which connects it to the common bile duct. Most of us know conditions like gallstones and gallbladder inflammation (cholecystitis) but there are also other types of gallbladder diseases which are less common. Gallbladder torsion is one of these uncommon conditions.  It is mainly seen in elderly women although it can occur in younger adults and children. Without prompt treatment, gallbladder torsion can lead to death.

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What is gallbladder torsion?

Gallbladder torsion, also known as gallbladder volvulus, is a condition where there gallbladder twists and in the process its blood flow is blocked. As a result the gallbladder tissue does not receive sufficient oxygen and  nutrients. This condition has to be treated surgically and early intervention is important as it may lead to fatal outcomes. Unfortunately gallbladder torsion is often missed since it is so condition and the symptoms may initially seem similar to many other more common gallbladder and abdominal conditions.

Overall, gallbladder torsion is a rare condition. It mainly occurs in the elderly, specifically those who are frail. Women are much more likely to suffer with this condition than men. The rise in incidence of gallbladder torsion in this century may be due to a longer life expectancy. Age-related changes in the supporting tissue of the gallbladder increases the risk of twisting. The link with gallstones is unclear but as many as 1 out of 3 people who develop gallbladder torsion/volvulus are found to have gallstones as well.

Causes of Twisted Gallbladder

The abdominal organs ares kept in place within the large abdominal cavity by a combination of overlying layers of tissue (peritoneum) and ligaments. Neighboring organs also support each other along with fat tissue. Although the organs can move to some extent, the supporting structures ensure that any movement of an individual organ is minimal. Twisting of the abdominal organs is uncommon but can occur with very long structures like the intestines (intestinal volvulus or twisted bowel). The gallbladder can also twist along the long axis on its pedicle.

The mesentery is a sheet of tissue that contains within it the arteries and veins that carry blood to and from the intestines. It also supports and supplies surrounding organs like the gallbladder. When there are anatomic variants in the mesentery or loss of visceral fat (fat tissue around the organs) then the gallbladder is free to move around more than it normally should. This is freely hanging gallbladder is also referred to as a “floating gallbladder”.

Other precipitating factors contribute to the twisting of the freely hanging gallbladder. This includes strong peristaltic contractions of neighboring organs, a downward shift in the abdominal organs from its normal position (visceroptosis), abnormal curvature of the spine (kyphoscoliosis) and weakened arteries running to the gallbladder.  The twisting can occur clockwise or counterclockwise. A clockwise rotation is associated with contractions within the stomach and small intestine (duodenum), while a counterclockwise rotation is linked to strong contractions in the transverse colon (large intestine).

The role of gallstones in the torsion is unclear. However, gallstones have been found in as many as 33% of patients with gallbladder torsion.

Types of Torsion

The twisting can be categorized as complete or incomplete. Complete torsion means that the twisting is more than 180 degrees while incomplete torsion is where thee is less than 180 degree twisting. It is the complete torsion that is considered to be the more serious type as it leads to occlusion of the blood vessels supplying the gallbladder. As a result the gallbladder tissue can die if treatment is not forthcoming thereby leading to a gangrene.

Signs and Symptoms

The signs and symptoms of gallbladder torsion are largely non-specific. This means that it does not conclusively point to gallbladder torsion. It includes:

  • Abdominal pain, specifically in the right upper quadrant.
  • Vomiting that often occurs with the pain.
  • Abdominal mass.
  • Abnormalities in the pulse and temperature.

Most of these symptoms are seen with a host of other abdominal conditions, many of which are more common that gallbladder torsion. Often conditions like acute pancreatitis and gallstones may first be suspected. The symptoms of gallbladder torsion may occur as recurrent episodes an gradually worsen over time if the torsion is incomplete. With complete torsion, the presentation is that of an acute abdomen and requires emergency medical attention.

Diagnosis of Gallbladder Torsion

The diagnosis of gallbladder torsion can be made with investigations like an abdominal ultrasound or computed tomography (CT) scan. A HIDA (hepatoiminodiacetic acid) scan and magnetic resonance cholangiopancreatography (MRCP) are some of the other imaging studies that can assist with visualizing the gallbladder and diagnosing torsion. Blood tests are not reliable although there is an elevation in white blood cell (WBC) count once the blood supply is affected by the twisting and when gangrene sets in. It is not uncommon for the diagnosis to be made with exploratory surgery.

Treatment and Prognosis

Gallbladder torsion has to be treated surgically. This can be done with laparoscopic (“keyhole”) surgery although open surgery may sometimes be necessary. Firstly the twisting has to be undone to prevent injury to the common bile duct, to which the cystic duct connects. Then the gallbladder has to be removed (cholecystectomy). Just undoing the torsion is not a solution as there is a significant risk of it recurring so gallbladder removal has to be done.

The outcome is good if the condition is diagnosed early and surgery is done as soon as possible. Severe cases can be life-threatening without prompt treatment. Less severe cases can cause complications like tenting of the common bile duct if the surgery is not conducted. Many of the patients with gallbladder torsion are elderly and may be frail or have other chronic conditions, which further complicates the outcome. Post-operative complications are less likely or severe with laparoscopic surgery.

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