Andrabi S I H, Med M A, Rathore M A.
Torsion of gallbladder: a diagnostic predicament.
J Coll Physicians Surg Pak Jan ;17(8):505-6.

A 69 years old woman was admitted under the case of physicians with lethargy and anemia. While in-hospital, she developed severe pain in the right hypochondrium with vomiting. Past medical history included peripheral vascular disease, appendicectomy and tuberculous meningitis. On examination, she had tachycardia, hypotension was pale, apyrexic, clinically anicteric and markedly tender over right upper quadrant with mild guarding. Her hemoglobin was 8.5 gm/dl, white cell count was 25,000 per uL and had a raised C Reactive Protein of 110. Her liver functions were normal. Plain abdominal radiograph revealed dilated small bowel in the upper abdomen. Provisional diagnosis of acute cholecystitis was made and conservative management was started initially, using intravenous cefuroxime. She deteriorated rapidly, developed metabolic acidosis and atrial fibrillation. CT scan did not reveal a significant abnormality. There were no gallstones and no evidence of acute cholecystitis. An emergency laparotomy revealed a gangrenous gallbladder and twisted more than 360o anticlockwise on its pedicle. Cholecystectomy was performed and she was managed in intensive care unit. She developed abdominal compartment syndrome requiring re-exploration and a laparostomy. On the fifth post-op day her abdomen was successfully closed with a mesh. Despite intensive monitoring and vigorous management, she developed multi-organ failure and died five weeks after her first operation. Histology confirmed venous infarction of an acalculous gallbladder without cholelithiasis.

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