Torsion of the gallbladder in pregnancy
A 36-year-old pregnant woman at 17 weeks of gestation presented to the Emergency Department with a one-day history of severe epigastric pain. The abdominal pain had started as epigastric discomfort that increased in intensity and then became more localized to the right upper quadrant. The pain was sharp and constant in nature. Physical examination revealed a thin woman (height, 165 cm; weight, 56 kg) with a blood pressure of 123/64 mmHg, a pulse of 80 beats/min, and a body temperature of 36.6℃. The abdomen was tender in the right upper quadrant. No guarding and rebound tenderness were noted. The laboratory data showed a white blood cell count of 9,700/mm3, a hemoglobin level of 11.8 g/dL, and the platelet count was 152,000/mm3. Other blood chemistry parameters including liver function test were unremarkable. Abdominal US demonstrated a distended gallbladder without stones but with mild wall thickening. Magnetic resonance imaging (MRI) demonstrated a slightly distended gallbladder with a markedly edematous and multilayered wall (). A diagnosis of acute cholecystitis was made, and antibiotics were administered; however, the patient's symptoms worsened. On the third hospital day, laparoscopic cholecystectomy using three-port was performed under the impression of an acalculous cholecystitis. The gallbladder was gangrenous and the body of the gallbladder had rotated 180° clockwise on the gallbladder mesentery (). The gallbladder was supported by the mesentery which was attached only to the proximal body of the gallbladder, thereby allowing the gallbladder to hang free. The gallbladder was untwisted and then removed without difficulty. Histopathological examination showed an acute gangrenous inflammation with extensive infarction. The postoperative course was uneventful and the patient was discharged on the 4th day after surgery.