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“Introduction Acute gallbladder volvulus continues to remain a relatively uncommon process, manifesting itself usually during exploration for an acute surgical abdomen with a presumptive diagnosis of acute selleck screening library cholecystitis. The pathophysiology is that of mechanical organo-axial torsion along the gallbladder’s longitudinal axis involving the cystic duct and cystic artery, and with a pre-requisite of local mesenteric redundancy. The demographic tendency selleck compound is septua- and octo-genarians of the female sex, and its overall
incidence is increasing, this being primarily attributed to increasing life expectancy. Despite significant challenges in pre-operative diagnosis, a high index of suspicion and prompt surgical intervention results in an overall mortality of approximately 5 percent. Case Report One A 99-year-old Caucasian female presented with a 3 day history of acute onset right upper quadrant abdominal pain with intermittent radiation to the right flank and back. It was described as colicky in nature on a baseline dull character, and with no obvious precipitating, aggravating or relieving factors. Associated phenomena included anorexia and nausea, but no constitutional upset, vomiting, or change in bowel habit. Her medical history
included peptic ulcer Serine/threonin kinase inhibitor disease, uncontrolled hypertension, tobacco abuse, diverticulosis, a hiatal hernia, and dementia. Her surgical history was significant for an appendectomy. Clinical physical examination revealed
an apyrexic frail patient in no acute distress with stable vital signs. Focused abdominal examination demonstrated a soft, mildly distended abdomen with tenderness to palpation in the right upper quadrant, and a positive Murphy’s sign. There was no overt peritonism. A reducible left inguinal hernia was also appreciated. Laboratory parameters yielded a mild leukocytosis with neutrophilia, and hypokalemia. Her liver function enzymes were elevated in a cholestatic distribution P-type ATPase with a total bilirubin of 3.9 mg/dL, direct bilirubin of 0.9 mg/dL, and an alkaline phosphatase of 150 IU/L. A computed tomography (CT) scan was initially obtained prior to surgical consultation; it demonstrated a largely distended, hydropic gallbladder, pericholecystic fluid with wall thickening, a dilated common bile duct and prominent intra-hepatic bile ducts (Figure 1). A hydroxyiminodiacetic acid (HIDA) scan was then recommended that showed an uptake of tracer into the liver with excretion into the small bowel but without gallbladder filling (Figure 2). Figure 1 Computed tomography scan in sagittal section demonstrating a large hydropic gallbladder. Figure 2 HIDA scan in Patient 1 demonstrating uptake of tracer in liver without visualization of the gallbladder; delayed images showed excretion of tracer into the small bowel. The patient and her durable power of attorney (DPOA) refused the recommended surgical intervention of cholecystectomy.