HPB P47 Torsion of a wandering gallbladder

Abstract Background Gallbladder torsion is an uncommon cause of acute abdomen. Despite over 500 reports published since 1898, only 10 cases of wandering gallbladder have been reported. In this anatomical variant (4-5% of the population) the gallbladder has no attachments to the liver. It is suspended only by the cystic duct and artery, which predisposes to twisting of the pedicle. Subsequent gallbladder necrosis can lead to rupture, peritonitis, sepsis and death (6%). Patients are typically elderly females, above the age of 70. A palpable gallbladder is described in 54% of cases. We report a rare case of wandering gallbladder leading to torsion. Methods An 89-year-old lady presented to emergency department with abdominal pain associated with vomiting and bowel not opened for five days. A palpable mass was evident on the right lower side of her small abdomen. Vital signs and lactate level were within normal range. Despite CRP was only moderately elevated on admission, it suddenly climbed to 504 within 24 hours. An abdominal CT scan showed a distended thick-walled gallbladder with a large stone, reported as “consistent with chronic calculous cholecystitis”. Results The patient was urgently brought to theatre for a laparoscopy where a free-floating gallbladder was found at the right lower quadrant, distended and gangrenous, rotated around its vascular axis. The surgery was converted to open due to lack of sufficient intra-abdominal space to accomplish the procedure. Her gallbladder was in the end successfully removed with no further concern and a washout of the peritoneal cavity was performed. The subhepatic drain was removed on day 1 postoperative. She recovered uneventfully and was discharged 12 days later due to social issues. Conclusions Despite rarely encountered, gallbladder torsion should be considered in the differential of patients presenting with acute abdomen, especially in case of rapid deterioration. Symptoms are nonspecific, as well as radiographic signs. A preoperative diagnosis is rarely made. If delayed, the condition may potentially become life-threatening. Surgical exploration is thus warranted and, once recognized, cholecystectomy remains the only resolutive treatment.