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LETTER TO THE EDITOR Table of Contents   
Year : 2011  |  Volume : 8  |  Issue : 2  |  Page : 262-263
Spontaneous gall bladder torsion with gangrene in a child: A rare case


Department of Pediatric Surgery, Mahatma Gandhi Medical College and Research Institute (MGMCRI), Pondicherry, India

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Date of Web Publication14-Oct-2011
 

How to cite this article:
Joshi M, Mahalakshmi V N. Spontaneous gall bladder torsion with gangrene in a child: A rare case. Afr J Paediatr Surg 2011;8:262-3

How to cite this URL:
Joshi M, Mahalakshmi V N. Spontaneous gall bladder torsion with gangrene in a child: A rare case. Afr J Paediatr Surg [serial online] 2011 [cited 2020 Oct 21];8:262-3. Available from: https://www.afrjpaedsurg.org/text.asp?2011/8/2/262/86084
Sir,

Spontaneous gall bladder torsion in children is rarely reported. Most commonly, it is reported in elderly females, with a 3:1 female preponderance. [1] We report a case of gangrene of gall bladder due to torsion in a child. Because of its extreme rarity, the incidence of this condition in children is not known.

A 9-year-old boy presented with complaints of pain abdomen and bilious vomiting of one day. On examination, there was fullness in the epigastrium, with signs of peritonitis and tenderness higher on the right side of the abdomen. Ryle's tube drained 500 ml of bile.

X-ray and ultrasonography of the abdomen showed dilated fluid-filled stomach and scanty gas shadows distally. Haematological investigations showed raised leucocyte counts.

On exploration through a right upper supraumbilical transverse incision, the gall bladder was found to be dilated and twisted 360 o counterclockwise on its axis at the neck and was gangrenous [Figure 1]. Approximately 50 cc of haemorrhagic fluid was present in the hepatorenal pouch. Cholecystectomy was performed. The child had a smooth postoperative recovery. The histopathology report showed a gangrenous gall bladder.
Figure 1: Operative photograph showing dilated gangrenous gall bladder due to torsion at the neck (see arrow

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Torsion of the gall bladder was first described in adults by Wendell in 1898 and, since then, around 350 cases have been reported in adults. [1] In the Japanese literature, 22 cases in children below 10 years have been reported. [2] Only isolated cases are reported in the English literature.

Predisposing factors involved in torsion of the gall bladder include anatomic variations like floating gall bladder and hourglass gall bladder, malnutrition, kyphoscoliosis, heavy meals and brisk activity. [1] In the presence of some anatomic variation, blunt trauma abdomen can also precipitate torsion. [3]

In torsion of more than 180 o , the vascular supply to the gall bladder is jeopardized, leading to gangrene. [1] Patients present with symptoms of acute cholecystitis. Less than 180 o torsion is often self-limiting and spontaneous detorsion may occur mimicking a biliary colic.

Because of its extreme rarity in children, preoperative diagnosis is difficult. However, 15 of 38 cases reported in the Japanese literature were diagnosed preoperatively. [4] Preoperative diagnosis was confirmed by computerized tomography scan, cholescintigraphy, intravenous cholangiography and, also, Magnetic resonance cholangiopancreatography (MRCP). [2],[3],[4] Surgery was performed after confirming diagnosis. Delayed treatment is associated with a 5% mortality in adults. [1] No morbidity or mortality data exist in children.

Dislocation of the gall bladder, thickening of the wall, swelling and mucosal fold at the neck and fluid in the hepatorenal pouch are some reported sonographic features of gall bladder torsion. [4],[5] Ultrasound may report a dilated, dislocated, hanging fundus of gall bladder as a duodenum.

We also emphasize the role of laparoscopy as both a diagnostic and a therapeutic tool in this condition for early cholecystectomy.

To conclude, such cases may not be picked up preoperatively unless the index of suspicion is high. If clinical signs are suggestive of acute cholecystitis with tenderness more localized on the right upper side of the abdomen, gall bladder torsion should be considered in the differential diagnosis in children. A history of precipitating factors should be carefully elicited. If ultrasonography supports clinical suspicion, then an approach by diagnostic laparoscopy will be a better plan of management.


   Acknowledgment Top


Dr. Anantha Krishnan, Professor Of Surgery and PG Coordinator, MGMCRI For reviewing the Manuscript

 
   References Top

1.Gonzalez-Fisher RF, Vargas-Ramirez L, Rescala-Baca E, Dergal-Badue E. Gallbladder volvulus. HPB Surg 1993;7:147-8.  Back to cited text no. 1
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2.Takano S, Takahashi M, Suzuki Y, Hazama K, Takahashi Y, Yoshioka T. A case of torsion of gall bladder in a child successfully diagnosed before surgery. J Jpn Surg Assoc 2003;64:964-8.  Back to cited text no. 2
    
3.Salman AB, Yildirgan MI, Celebi F. Post traumatic gall bladder torsion in a child. J Pediatr Surg 1996;31:1586.  Back to cited text no. 3
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4.Kouchi K, Kawamura K, Kuriya Y. Torsion of gall bladder in a seven year old boy. J Jpn Soc Pediatr Surg 1996;32:916-7.  Back to cited text no. 4
    
5.Komura J, Yano H, Tanaka Y, Tsuru T. Torsion of the gall bladder in a thirteen year old boy - Case report. Kurume Med J 1993;40:13-6.  Back to cited text no. 5
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Correspondence Address:
Manoj Joshi
4D Staff Quarters Type 1, Mahatma Gandhi Medical College and Research Institute, Pondicherry - 607 402
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-6725.86084

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