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Torsion of suprahepatic gall bladder
Woo Young Nho1, Jae Oh Kim2, Soon Young Nam2, Se Kook Kee2
1 Department of Emergency Medicine, Gumi CHA Medical Center, CHA University, Gumi, Republic of Korea
2 Department of Surgery, Gumi CHA Medical Center, CHA University, Gumi, Republic of Korea
|Date of Submission||11-Aug-2020|
|Date of Decision||27-Sep-2020|
|Date of Acceptance||29-Sep-2020|
|Date of Web Publication||24-Apr-2021|
Se Kook Kee,
Department of Surgery, Gumi CHA Medical Center, CHA University, 12 Sinsi-ro 10 Gil, Gumi 39295
Republic of Korea
Source of Support: None, Conflict of Interest: None
Suprahepatic gall bladder is rare, and torsion of the ectopic gall bladder is extremely rare. We report a patient of acute suprahepatic cholecystitis with torsion. A 69-year-old Korean male was admitted to our hospital for sudden-onset, severe epigastric pain. Abdominal computed tomography and ultrasonography showed a distended gall bladder with diffuse wall thickening and scanty pericholecystic fluid, which was located in ectopic suprahepatic position, accompanied by S4 hypotrophy of the liver without gallstones. Emergency laparoscopic cholecystectomy was performed, and intraoperative findings revealed a distended and ischaemic gall bladder that was located in the suprahepatic position and had twisted along the cystic duct and artery pedicle in a clockwise manner. Detorsion was done and the gall bladder was resected. Unfortunately, the pre-operative diagnosis of gall bladder torsion was missed, and a definite diagnosis was made at the time of surgery. The patient was discharged on the 4th post-operative day.
Keywords: Gall bladder torsion, S4 hypotrophy, suprahepatic gall bladder
| ¤ Introduction|| |
Among the uncommon ectopic gall bladder, suprahepatic position is rare. Moreover, torsion of suprahepatic gall bladder has hardly been reported. We report the case of acute gangrenous cholecystitis in torsed suprahepatic gall bladder.
| ¤ Case Report|| |
A 69-year-old Korean male presented to the emergency department with severe epigastric pain. Physical examination showed that his vital signs were normal without fever. The abdomen was not distended, but there was localised tenderness in the epigastric and right upper quadrant area. Laboratory findings showed a normal complete blood count, and liver function tests revealed a serum total bilirubin level of 0.5 mg/dl, a serum aspartate aminotransferase of 45 U/L and a serum amylase level of 78 U/L. All other studies were within the reference limits. A plain radiography showed a localised ileus. A contrast-enhanced computed tomography (CT) demonstrated a distended gall bladder with diffuse wall thickening and presence of scanty fluid in the pericholecystic area. The gall bladder was located in the suprahepatic position, accompanied by hypotrophy of the liver segment 4 (S4) without displacement of the colon. Ultrasonography revealed a distended gall bladder with diffuse wall thickening in the suprahepatic space, and no gallstones were noted [Figure 1]. The patient was admitted with a clinical diagnosis of acute cholecystitis. Emergent laparoscopic cholecystectomy was scheduled on the same day of patient arrival. Intraoperative findings revealed a distended gall bladder with ischaemic change, which was located in the suprahepatic position and had twisted along the cystic duct and artery pedicle in a clockwise manner. There were a prominent main portal fissure and an elongated mesentery with minimal peritoneal attachment [Figure 2]. Detorsion of the twisted gall bladder was performed and the gall bladder was resected. The resected gall bladder was about 11 cm in length and had a thickened oedematous wall with gangrenous change. There were no stones in the gall bladder lumen, and yellow streaks were diffusely distributed on the gangrenous mucosa. Microscopic findings of the gall bladder were consistent with those of acute gangrenous cholecystitis. Unfortunately, the pre-operative diagnosis of gall bladder torsion was missed, and a definite diagnosis was made at the time of surgery. The post-operative period was uneventful, and the patient was discharged on the 4th post-operative day. This case study was approved by the Institutional Review Board (IRB) of Gumi CHA Medical Center (GM20-02), and the IRB waived informed consent for this reporting.
|Figure 1: (a) Distended suprahepatic gall bladder accompanied by hypotrophy of the S4. (b) Prominent main portal fissure (arrow). (c) Computed tomography scans done 8 years before presentation: focal enhancing portion in the S4 (black arrow) (d) Computed tomography scans done 3 years before presentation|
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|Figure 2: Operative findings. (a) A distended and gangrenous suprahepatic gall bladder. (b) Twisted along the cystic duct and artery pedicle in a clockwise manner. (c) Detorsion was done. (d) Cholecystectomy was done|
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| ¤ Discussion|| |
Ectopic position of gall bladder is one of the unusual findings in gall bladder anomaly. Ectopic gall bladders are classified into several types, as follows: transverse, left sided, intrahepatic, retrohepatic and suprahepatic. The incidence of ectopic gall bladder had been reported in <1% of the general population.,, Suprahepatic space is the most uncommon position, and only few cases have been reported since the first report by Regen and Poindexter in 1965.,, Torsion of suprahepatic gall bladder is extremely rare, and countable cases have been reported for several decades. Suprahepatic gall bladder is usually associated with hypoplasia or atrophies of the right liver lobe. It may be secondary to congenital malformation, cirrhotic hypoplasia, hepatic vascular injury or the presence of diffuse cholangiocarcinoma., These physical conditions are usually accompanied by upwards migration of the hepatic flexure. The diagnosis can be made by ultrasonography, CT scan or magnetic resonance cholecystopancreatography. We reviewed the previous CT images of our patient, which were taken 3 and 8 years ago from presentation for regular medical screening. Older images showed suprahepatic gall bladder and liver S4 hypotrophy. On comparing the images taken 8 years ago with that taken 3 years ago, it was evident that the degree of liver S4 hypotrophy has more progressed during the 5-year period. In addition, the S4 parenchyma was atrophied and became fibrotic [Figure 3] in the recent images. Consequently, the suprahepatic gall bladder had been more mobile and more prone to rotate in the suprahepatic space, which could have resulted in torsion of the gall bladder. Surgery is indicated in symptomatic patients. Laparoscopic cholecystectomy is now recommended as the first choice of treatment. Some authors supposed surgery in asymptomatic patients with suprahepatic gall bladder due to a higher incidence of compression or torsion of the cystic duct, bile stasis, calculus formation and acute cholecystitis., In conclusion, suprahepatic gall bladder is rare, and torsion of ectopic gall bladder is extremely rare. Surgery is indicated in patients with symptomatic suprahepatic gall bladder and considered even in asymptomatic cases to reduce the resultant mortality.
|Figure 3: Serial contrast enhanced axial CT scans (a) 8 years ago: focal geographic enhancing portion in the segment IV (black arrow) around the inferior vena cava. (b) 3 years ago: size of the enhancing portion decreased for 5 years. (c) Present CT: shows progressive retraction and reduced enhancement of the segment IV (arrowhead), and widening of the main portal fissure (white arrow). This hepatic lesion is probably focal confluent fibrosis|
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]