We present a case of acute torsion of the gallbladder in a young woman. Approximately 400 cases have been reported since 1898, mostly in elderly women, and the incidence appears to be increasing. The anatomy and pathophysiology that predispose patients to this rare surgical emergency are discussed. Several clinical and imaging findings can be used to distinguish gallbladder torsion from typical acute cholecystitis. By recognizing and treating gallbladder torsion early in its course, a low surgical morbidity and mortality can be achieved. The case presented highlights for emergency physicians some of the considerations in identification of patients with acute cholecystitis who are at highest risk of gangrene and perforation, their emergency treatment, and the timing of surgery.

Gallbladder torsion is rare cause of acute abdomen. Although gallbladder torsion is considered a difficult disease to diagnose preoperatively, prompt surgical intervention is necessary catastrophic consequences. There are some radiological findings consistent with torsion of the gallbladder (GB) that should raise a high index of suspicion for this condition. A 35-yo woman presented to our ED with a 24-h history of abdominal pain. The pain began in the periumbilical region and migrated to the right side of the abdomen and was associated with nausea, and one episode of emesis. Physical examination revealed a young female patient in mild distress, with tachycardia (100 beats/min); all other vital signs were normal. The abdomen was not distended. She had generalized tenderness over the entire right side with rebound tenderness and peritoneal sings over the right mid abdomen. Lab values showed a WBC count of 10,700 cells/mm3 and normal LFTs. RUQ ultrasound showed a well distended GB and no evidence of calculus. The GB wall measured 7mm. There was a small amount of pericholecystic fluid. The common bile duct measured 4mm. Ultrasound Murphy's sign was positive. HIDA scan was performed which showed that the GB did not fill in 3,5 hours. All diagnostic evidence pointed to GB pathology, however the patient was given analgesics in the ED and was found to be pain free at surgical examination. The abdominal exam worsened during hospital admission, and the WBC count increased to 12,800 cells/mm3 with 95% of neutrophiles. CT scan of the abdomen was performed. The appendix was not visualized, but there was pericholecystic and pelvic fluid. With a preoperative diagnoses of acute cholecystitis the patient was taken to the OR for exploratory laparoscopy. On visualization the GB wall was black diffusely. There was no mesentery to the GB. The GB was freely mobile and was attached by its cystic duct and cystic artery, and was volvulized. Laparoscopic cholecystectomy was performed with intraoperative cholangiogram. The pathology report revealed an ischemic appearing GB. The GB culture revealed no growth. The patient recovered uneventfully and she was discharged the day after surgery. Our case was not identified preoperatively as GB torsion. but probably should have been because of the positive hepatobiliary scan in the absence of gallstones on ultrasound and the acute severe right upper quadrant symptoms on presentation.

Abdominal compartment syndrome is a well-documented entity arising from multiple and various causes. The rise of intra-abdominal pressure by the increase in volume of the peritoneal and retroperitoneal contents has been shown in the resuscitation and evaluation of surgical patients. However, the incidence of constriction of the abdomen causing intra-abdominal hypertension is unknown. Previously limited to burn eschar and externally applied devices (such as MAST trousers), external compression leading to abdominal compartment syndrome has been a limited entity. We report the first documented case of an expansive abdominal wall mass, a rectus sheath hematoma, leading to impending abdominal compartment syndrome.