Acute Gallbladder Volvulus in a 93-Year-Old High-Risk Patient: A Case Report

Introduction

A gallbladder volvulus is a rare surgical emergency, with less than 500 cases described in the literature to date [1]. Typically, it affects asthenic patients older than 60 years of age, with a female-to-male ratio of 4: 1. A correct preoperative diagnosis is crucial to avoid life-threatening complications, but is often hampered by non-specific imaging findings. Apart from typical signs for an acute cholecystitis such as pericholecystic fluid and a thickening of the gallbladder wall that are also regularly found in patients with gallbladder volvulus, more specific findings like a “whirl sign” due to a twisted cystic artery or a position of the gallbladder outside its anatomical fossa are only seen in about one-fourth of cases [2].

Here, we describe the case of a 93-year-old woman with an acute gall bladder volvulus that was misdiagnosed as acalculous cholecystitis and initially managed conservatively due to a symptomatic, high-grade aortic valve stenosis.

Case Report

A 93-year-old woman presented to the emergency department with a 3-h history of right upper-quadrant pain and nausea. She described a sudden onset of symptoms immediately after breakfast, with extreme pain. She had a known background of autoimmune hepatitis type 1/primary biliary cholangitis overlap syndrome with moderate liver fibrosis, currently being treated with ursodeoxycholic acid and azathioprine. Moreover, she had recurrent dizziness and a tendency to fall due to a high-grade aortic valve stenosis (Vmax 4.2 m/s, dpmax/mean 72/40 mmHg, AVA 0.8 cm2) that had led to several hospital admissions in the recent past. The patient was under consideration for a transcatheter aortic valve implantation (TAVI) at the time, but had not decided to go ahead with the procedure. She was on antiplatelet medication with 100 mg of aspirin daily. Other regular medications included metoprolol for arterial hypertension, rosuvastatin, folic acid, and vitamin D3.

Upon presentation, she was hemodynamically stable and afebrile (blood pressure 176/128 mmHg, heart rate 81 beats per minute, body temperature 36.9°C). She was in slightly suboptimal general condition, but was oriented to person, place, and time. She was slender, with a body mass index of 22.3 kg/m2. On examination, she was tender in the right upper quadrant, but without local peritonitis and with a negative Murphy sign. Interestingly, her pain and nausea did not respond well to analgesia and antiemetics. An ultrasound of the abdomen was performed, showing a distended gall bladder with what was thought to be sludge and a wall thickening suspicious for an acute cholecystitis (Figure 1). The common bile duct was slightly dilated to 12 mm, but with no evidence of choledocholithiasis and no intrahepatic cholestasis.

Blood tests revealed a significantly elevated lactate of 4.2 mmol/L (ref. 0.5–2.2 mmol/L) and a slight increase in LDH was seen (277 U/l, ref. <250). Full blood count, CRP, urea, electrolytes, coagulation studies, liver function tests, and lipase were within normal limits. To rule out a mesenteric ischemia or a hollow viscus perforation on the background of previous gastric ulcers, a CT scan of the abdomen was performed, confirming the suspected diagnosis of an acute cholecystitis (Figure 2).

Given her advanced age, the significantly increased operative risk in view of the high-grade aortic valve stenosis, an ASA score of 4, and a calculated Charlson Comorbidity Index of 7 with an estimated 10-year survival of 0%, a conservative approach with antibiotics was advised. She was admitted to the general medicine ward and received i.v. piperacillin/tazobactam, as well as analgesic and antiemetic medication. However, her pain worsened, with focal peritonitis in the right upper quadrant on clinical examination, and her inflammatory markers 2 days after admission showed a sharp increase, with a CRP level of 213 mg/l (ref. <5) and a WBC of 15.9×103/μl (ref. 4–11). A repeat bedside ultrasound showed some free fluid surrounding the gallbladder and liver, which had not been seen before, raising suspicion for a gallbladder perforation.

As the conservative management had failed, a thorough discussion with the patient about interventional treatment with a cholecystostomy tube versus surgery took place. The patient wanted a definitive solution and refused a prolonged treatment with a drainage tube, so it was decided to proceed with surgery despite the significantly increased perioperative risk. She underwent surgery the same evening, 2 days after admission to the hospital. A laparoscopic approach with a low threshold for conversion was planned upon consultation with the responsible anesthetists. A low-pressure pneumoperitoneum with a maximum of 8 mmHg was established, which was tolerated by the patient.

Intraoperatively, a distended, necrotic gallbladder was found, surrounded by turbid fluid with focal peritonitis and fibrin deposits, but no frank perforation (Figure 3). The gallbladder was partially decompressed with a Veress needle, aspirating blood-stained fluid but no bile. Further examination revealed a 360° gallbladder volvulus in a counterclockwise direction (Figure 4). After reduction of the volvulus, a long and mobile gallbladder mesentery was found (Figure 5). The cystic duct and cystic artery were identified and divided between clips. Upon releasing the gallbladder from its fossa, it became obvious that there was only a very small area of attachment of the gallbladder to the liver bed, which allowed twisting around the cystic duct/cystic artery axis (Figure 6). There were no intraoperative complications and the surgery was completed laparoscopically. The total duration of surgery was 72 min and the estimated blood loss was less than 30 ml.

The patient was extubated in the operating room, and as a precaution spent 1 night in the intensive care unit before being transferred to the general ward the next day. Further recovery was uneventful. Due to the local peritonitis, i.v. antibiotics were continued postoperatively. She was discharged to home on the third postoperative day with a further course of oral antibiotics. During follow-up with her general practitioner 1 week later and again after 3 months, there were no further issues noticed. The histopathological findings showed a hemorrhagic infarction of the gallbladder with complete necrotic disintegration of the tissues and no evidence of malignancy.

Discussion

A gallbladder volvulus is a rare surgical emergency with an estimated incidence of 1 in 350 000 hospital admissions and refers to a torsion of the gallbladder around the cystic duct/cystic artery axis, which often leads to ischemia and necrosis [1]. This pathomechanism explains why an antibiotic treatment, which is commonly attempted in older patients due to the often wrongly suspected diagnosis of an acalculous cholecystitis, cannot successfully treat the underlying cause of this condition. A late or missed diagnosis likely leads to a perforation of the gallbladder, causing peritonitis and sepsis, and is reflected in a mortality rate of 6%. The deaths in all cases in the corresponding literature occurred in patients in whom the torsion was not detected preoperatively [1,3].

Ultrasound remains the standard initial diagnostic tool for gallbladder diseases. In case of a torsion, a reduced perfusion of the gallbladder wall with pericholecystic fluid and an abnormal position outside the gall bladder fossa can be seen. Interestingly, stones are found in only one-third of these patients and are not thought to play any role in the etiology of the condition. CT findings suggestive of a gallbladder volvulus include a “whirl sign” due to the twisted cystic artery, a large “floating” gallbladder with surrounding fluid, and a position outside its normal fossa [2]. However, some or all these signs may be absent or missed, leading to an accurate preoperative diagnosis in only 26% of cases [4]. Retrospectively, in our case, there were no clear signs for a gallbladder volvulus in the preoperative ultrasound or CT imaging apart from a slightly low-lying gallbladder. Notwithstanding this, our patient was clearly in the at-risk population – in the literature, asthenic, female patients with a median age of 77 years at presentation are most commonly affected [2].

Our patient’s symptomatic high-grade aortic valve stenosis posed significant challenges for laparoscopic surgery, which we preferred over an open approach to ensure a quick postoperative recovery as the patient was living alone and independently, despite her advanced age, due to reduced blood loss during surgery and shorter hospital stay. Furthermore, the pooled risk of complications was shown to be lower in patients undergoing laparoscopic surgery, leading to a reduced mortality within the first 3 months after surgery [6,7].

Nevertheless, symptomatic, high-grade aortic valve stenosis is a severe risk factor leading to significantly increased postoperative morbidity and mortality as it reduces coronary perfusion under surgical stress and hemodynamic changes, which can lead to myocardial infarction and/or heart failure. In laparoscopic surgery, the pneumoperitoneum decreases cardiac output and pulmonary compliance, which increases the risk for postoperative heart failure and myocardial infarction even further [8,9]. A preoperative valve intervention, which should be evaluated according to the current ESC guidelines, did not seem feasible given our patient’s high inflammatory markers, worsening abdominal findings with focal peritonism in the right upper quadrant, and ultrasound findings suspicious for a gallbladder perforation and risk of sepsis [10]. However, there is no reliable information on the safety and feasibility of laparoscopic surgery in patients with symptomatic, high-grade aortic valve stenosis.

The standard pressure pneumoperitoneum is 12 mmHg at our center and ranges between 12 and 16 mmHg in many other centers worldwide [11]. In close consultation and coordination with our anesthesiology team, we decided to proceed with laparoscopic surgery with a low-pressure pneumoperitoneum of 6 mmHg initially and a further increase to 8 mmHg, which was well tolerated by the patient. The intraoperative view was sufficient despite the lower pressure, and the surgery was completed without any hemodynamic complications during surgery or in the further postoperative course.

Conclusions

Gallbladder volvulus is a rare condition with a high mortality rate if not diagnosed correctly. Timely surgery with cholecystectomy remains the standard treatment. As preoperative imaging often fails to demonstrate the torsion of the gallbladder itself, it should be kept in mind as an important differential diagnosis, especially in older female patients with slender build and a presumed diagnosis of acalculous cholecystitis. Laparoscopic cholecystectomy may be attempted even in the context of a severe aortic stenosis if there are close intraoperative monitoring and interdisciplinary communication.