DISCUSSION:
Acute cholecystitis is a common emergent pathology, which is rarely due
to Gallbladder torsion. This mechanism can be explaining by ischemia of
its wall than necrosis [3].
Its etiology is not yet been identified, factors studied in the
literature involved anatomical abnormalities such as a long gallbladder
mesentery, providing it the possibility to tilt freely from the liver
bed and easily twist upon itself. [4]
The mechanical events may be suddenly changing in body position, violent
peristalsis of adjacent internal organs, and blunt injuries. Studies
have shown that level elevation of cholecystokinin causing by
gallbladder peristalsis after a fatty meal may conclude to gallbladder
torsion[5].
This is due to a gallbladder without adhesion to the liver, concluding
to the torsional movement. Referring to the literature: The Gross
classification studied the types of gallbladder mobility according to
the adherence with the life concluding to two types. Type I corresponds
to the attachment of the gallbladder and cystic duct to the lower
surface of the liver through the mesentery. In Type II, the cystic duct
alone is attached to the liver[3]
Clinical symptoms are not distinctive and could comprise abdominal pain,
nausea, and vomiting, and a palpable mass. A triple triad has been
identified to clinically dissimilate between acute cholecystitis and
gallbladder volvulus: the first is patient features, The second is based
on clinical signs of intense onset pain, right upper quadrant pain, and
vomiting, The third is of clinical characteristics on physical
examination: a palpable mass in the right upper quadrant[1].
laboratory data of gallbladder torsion often indicate elevated
inflammatory response. However there is a normal liver function, such in
our case.
Ultrasound is viewed as the first mean of diagnosis and often revealing
a large floating gallbladder without gallstones, and a thickened
gallbladder wall[6]. Other more specific signs can be seen such as
the presence of the gallbladder outside its normal anatomic fossa and a
knot sign [6].
CT scan is viewed as the first means for the diagnosis and it usually
described a swollen gallbladder with wall thickening and no
gallstones[2], often associated with the abrupt tapering of the
cystic duct [2],indirect signs of the necrosing process which are
pericholecystic fluid and thumb printing of the gallbladder [6].
Also, it can demonstrate a free-floating gallbladder such as Whirl Sign
and cystic duct knot sign, which are surely pathognomonic for
gallbladder torsion[6].
Treatment of gallbladder volvulus is emergency cholecystectomy, as its
delay might increase the risk of perforation, peritonitis, and death.
the laparoscopic approach is the gold standard and it should begin with
a release of the torsion, thus avoiding damage to the main bile
duct[3].
Delaying diagnosis and treatment can result in bilious peritonitis,
which would increase mortality.