What is Gallbladder Volvulus?
Gallbladder volvulus, or GV, is a rare condition that causes severe stomach pain. It was first identified in 1898 as a “floating gallbladder”. This condition is so serious that quick surgery is needed. However, it’s often diagnosed during the surgery itself rather than beforehand. To give you an idea of how rare this condition is, out of 365,000 cases related to gallstones, only one is likely to be gallbladder volvulus.
What Causes Gallbladder Volvulus?
Gallbladder torsion, known as GV, is a rare condition where the gallbladder twists around its connecting tissue, known as the mesentery. This sometimes happens when there’s an abnormality in the blood vessel leading to the gallbladder, or when the tissue connecting the gallbladder to the liver bed is unusually long, allowing the gallbladder too much movement.
In such a situation, the gallbladder can twist around the duct and artery that carry bile and blood to and from it. As people age, they tend to lose the fat inside their abdomen, which seems to make gallbladder torsion more common in older people.
Besides that, certain factors might contribute to the development of this condition, such as the movement of the surrounding bowel, spinal deformities, and a winding, hardened cystic artery (a blood vessel that may become hardened due to plaque buildup, a condition called atherosclerosis).
Risk Factors and Frequency for Gallbladder Volvulus
Gallbladder volvulus, or a twisted gallbladder, is a medical condition that can occur in people of all ages, but is most often seen in older individuals, especially women in their seventies and eighties. Women are three times more likely to have this condition than men. While it is generally treatable, about 6% of cases result in death.
- Gallbladder volvulus can affect people of all ages, but it’s most common in the elderly.
- Women in their seventies and eighties are often affected.
- The condition is three times more common in women than in men.
- It has a mortality rate of 6%.
Signs and Symptoms of Gallbladder Volvulus
When people arrive at the emergency room with severe pain in their abdomen, it might be due to gallbladder torsion, a condition where the gallbladder twists around. Its symptoms remind us of constant bile duct pain and partial torsion, although, in total torsion cases, patients usually have a history of sudden, severe upper-right abdominal pain and accompanying vomiting. Sometimes, there may be a noticeable lump in the stomach. Typically, there’s no signs of poisoning or skin and eyes turning yellow as seen in jaundice.
Diagnosing gallbladder torsion before surgery is challenging due to the general symptoms and signs that could also indicate an infection. Often, the symptoms might even resemble other conditions like appendicitis or blocked blood supply to the bowel. Regardless of the direction of the twist, the result is the same: it cuts off the blood supply, leading to tissue death and decay.
Normally, doctors may first think that the patient has an infection, and provide treatments like fluid resuscitation to restore blood flow and antibiotics to fight infection. However, if the patient’s symptoms persist despite receiving treatment for a right-sided abdominal condition, doctors should consider the possibility of gallbladder torsion.
Testing for Gallbladder Volvulus
Diagnosing gallbladder volvulus or a twisted gallbladder can be quite challenging for doctors and radiologists, even with the latest lab tests and imaging techniques. Lab results for liver function are often unclear in cases of incomplete twisting of the gallbladder. However, they might notice a higher than usual white cell count and C-reactive protein level, which are indicators of inflammation.
To get more specific information, doctors often rely on imaging tests starting with an ultrasound. Certain features seen on the ultrasound can be indicative of a twisted gallbladder:
1. A swollen and dark appearing gallbladder wall, which is an indication of inflammation and eventual death of the gallbladder tissue.
2. A “floating gallbladder” that no longer attaches to the liver.
3. A cone-like structure at the base of the gallbladder with multiple bright lines coming together at the tip of the “cone.”
CT scans and MRIs are also commonly used. A CT scan can show the “floating gallbladder” and thickened gallbladder wall. An MRI is particularly good at visualizing the twisted duct that is connected to the gallbladder. It can also show if the gallbladder tissue is dying.
Another type of test, known as a HIDA scan, can show an unusual “bullseye” appearance due to the buildup of a radioactive substance in the gallbladder. This is another indication that the gallbladder might be twisted.
In addition to these imaging tests, a procedure called upper GI endoscopy may be used for diagnosis. This involves inserting a flexible tube down the throat to visually inspect the upper part of the digestive tract. Diagnosis can be confirmed if doctors find abnormal distortions, difficulty accessing the stomach and pylorus (the lower part of the stomach), or see signs of tissue death in later stages of the disease.
Spotting a twisted gallbladder early is crucial to avoid serious complications, such as the gallbladder tissue dying, the gallbladder bursting causing an infection of the internal lining of the abdomen, and other infections. Quick use of appropriate imaging tests can help prevent these complications, lower the chances of death and illness, and reduce hospital costs.
Treatment Options for Gallbladder Volvulus
When a medical condition called acute GV, or gallbladder volvulus, is identified or strongly suspected, immediate surgery is required. The appropriate operation in this case is an emergency cholecystectomy, which is a surgical procedure to remove the gallbladder.
This operation can be carried out using two methods – an open approach, where a large cut is made, or a laparoscopic approach, where the operation is performed through several small incisions. An important part of the operation is carefully releasing and repositioning the gallbladder to clearly see the surrounding structures. This must be done very meticulously, as parts of the bile duct system may be in abnormal positions due to the twisting of the gallbladder, making them vulnerable to accidental damage during the surgery.
When immediate surgery is performed for this condition, the patient’s outlook is generally very good. However, any delay in surgery may result in more severe complications, such as tissue death and infection in the gallbladder, which can lead to a condition called bilious peritonitis, causing an increase in patient sickness and risk of death.
What else can Gallbladder Volvulus be?
Here are some conditions that may appear similar to other gastrointestinal issues:
- Ileosigmoid knot
- Pseudo-obstruction
- Severe constipation
- Severe sigmoid diverticular disease