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.