“” Ultrasound image in Patient 2 of a markedly enlarged gallbladder

with a multi-layered hypoechoic rim demonstrating an edematous wall without calculi – the so-called classic description Figure 6 HIDA scan in Patient 2 demonstrating non-filling of the gallbladder consistent with cystic duct obstruction. After appropriate consent, the patient was taken to the operating room for a selleck inhibitor laparoscopic cholecystectomy with a pre-operative diagnosis of acute cholecystitis. After entering the Cyclosporin A in vitro peritoneal cavity and appropriate establishment of pneumoperitoneum, exploration quickly revealed an obvious necrotic gallbladder in the right upper quadrant. Further investigation noted that the gallbladder was twisted 180 degrees on its small pedicle with a thrombosed cystic artery. Following reduction of the torsion, the gallbladder was resected in the standard laparoscopic fashion. Histology demonstrated congested and ischemic serosa with necrotic mucosa consistent with torsion. Her post-operative course was unremarkable and she was discharged on post-operative day 1. Discussion First reported by Wendel in 1898, and dubbed the “”floating

gallbladder”", gallbladder volvulus is a recognized surgical entity [1]. It commonly affects women in their seventies and eighties, and the increased incidence of this condition may be attributable to increasing life expectancy. Despite its predilection for older learn more ages, it has also been described in the pediatric population as early Megestrol Acetate as 2 years of age [2]. Multiple hypotheses have been proposed as to the mechanism of gallbladder torsion, but the exact etiology continues to be unidentified. The pre-requisite of local mesenteric redundancy however is necessary for organo-axial torsion around its pedicle. Two anatomic variants have been described: 1) a torsion-prone mesentery, and 2) a mesentery supporting only the cystic duct allowing a completely peritonealized gallbladder to hang free. The susceptibility for rotational instability may be compounded by the elderly’s fat loss and tissue atrophy suspending the gallbladder

freely [3]. This was seen in both cases a probable precipitant for torsion. Further mechanisms may include violent peristaltic movements of neighboring organs, visceroptosis, and a tortuous atherosclerotic cystic artery [3]. Kyphoscoliosis of the spine has also been implicated as a fulcrum for torsion and was noted retrospectively in our first patient (Figure 7). An association of Saint’s triad – the collection of diverticular disease, a hiatal hernia, and biliary pathology – has been previously reported by McAleese et al; this relationship may also be attributable to our first case when reviewing her history and to our knowledge, is the only other report of this association in the literature [4]. Nakao et al investigated 245 cases in the Japanese literature noting that cholelithiasis is an infrequent cause of gallbladder volvulus; gallstones were demonstrated in only a quarter of patients afflicted [5].