Introduction

Gallbladder torsion is a rare condition, predominantly affecting elderly women. It is an important condition in the differential diagnosis of acute surgical abdomen. We report a case of torsion of the gallbladder under the right subphrenic space in a patient with liver cirrhosis. We here present a very rare case of torsion of the gallbladder displaced under the right subphrenic space in a patient with liver cirrhosis.

Case report

An 82-year-old Japanese woman was admitted to our hospital for acute pain in the right upper quadrant. There was no history of previous abdominal surgery. She had acute abdominal pain and developed fever the day after admission. Physical examination showed tenderness in the right upper quadrant, body temperature of 37.9 °C, pulse rate of 98 beats/min, and blood pressure of 120/69 mmHg. Height was 153.7 cm, weight was 48.3 kg and body mass index was 20.4. Laboratory data showed leukocyte count of 16,900/μl, CRP of 6.63 mg/dl. Liver test and bilirubin were normal. Abdominal computerized tomography (CT) showed the swollen fundus and body of the gallbladder located under the right subphrenic space (Fig. 1a). Drop infusion CT (DIC-CT) showed no contrast effect in the cystic duct and gallbladder (Fig. 1b). Cystic duct was not depicted. The established diagnosis was torsion of the gallbladder requiring emergency laparoscopic surgery. Intraoperative examination showed liver cirrhosis with the undersurface of the right subphrenic space coated with the greater omentum (Fig. 2a). Bile juice leakage was evident together with 360° gallbladder twist in clockwise direction (Fig. 2b). Laparoscopic cholecystectomy was performed together with radical surgery for peritonitis. Macroscopically, the wall of the gallbladder was black. Histological examination of the gallbladder revealed necrosis of the epithelium with edema. These findings rapid ischemic changes. The postoperative course was uneventful and the patient was discharged on postoperative day 11.

Fig. 1
figure 1

a, b Computed tomography. Axial images were obtained with computed tomography. The swollen fundus and body of the gallbladder were located under right subphrenic space (a), drop infusion CT (DIC-CT) showed no contrast effect in the cystic duct and gallbladder (b)

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Fig. 2
figure 2

a, b Intraoperative findings. Intraoperative findings included liver cirrhosis (a), coating of the right subphrenic space with the greater omentum (a), bile juice leakage, gallbladder with 360° twist in clockwise direction (b)

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Discussion

We reported the first case of torsion of the gallbladder under the right subphrenic space. Our search of the English literature found no similar cases. In our patient, right liver lobe atrophy due to liver cirrhosis was considered a contributing factor. In all previously reported cases of torsion of the gallbladder, the twisted sac was found underneath the liver [1, 2].

Torsion of the gallbladder usually affects elderly subjects with a higher incidence in women than men [3]. Predisposing factors include descent of internal organs, such as tortoise back and thin body [3, 4]. In our case, the patient was an elderly woman with a thin body and tortoise back. Most cases of gallbladder torsion present with sudden-onset complete torsion, which can compromise the blood supply to the gallbladder and cause gallbladder gangrene, perforation, and subsequent diffuse peritonitis. Therefore, gallbladder torsion is considered a life-threatening emergency. If gallbladder torsion is diagnosed or highly suspected, surgical resection of the gallbladder should be performed promptly. Laparoscopy is currently the preferred approach for both diagnosis and treatment [5].

CT scans sometimes identify the abnormal anatomical position of the gallbladder as well as gallbladder wall thickening and pericholecystitic fluid. Multidetector CT (MDCT) has also been used successfully for the preoperative diagnosis of gallbladder torsion [6, 7]. DIC-CT was used in the present and correctly diagnosed the position of the gall bladder.

A floating gallbladder can easily be twisted at the level of attachment to the liver bed. Furthermore, the right side diaphragm can be stretched by the displaced gallbladder. This, together with physical factors, such as sudden change in body position and intraperitoneal pressure, could perhaps facilitate displacement and torsion of a floating gallbladder. The floating gallbladder, right subphrenic space, and right liver lobe atrophy, contributed to the strangulation and resulted in acute ischemic cholecystitis requiring emergency surgical intervention. Our patient showed favorable and rapid postoperative recovery. This was a reflection, at least in part, of to the advantages of minimally invasive surgical approach followed in this patient.

In conclusion, the clinical features and imaging findings of strangulated gallbladder under the right subphrenic space with liver cirrhosis are similar to those of other forms of torsion of the gallbladder. Appropriate diagnosis and prompt surgical treatment are essential for a positive outcome.