Gallbladder Volvulus: An Unusual Presentation.

BACKGROUND Gallbladder torsion is a rare entity of acute abdomen that can be fatal if not diagnosed and treated promptly. It presents in a multitude of ways but the most common is a presentation similar to acute cholecystitis. Diagnosis can be made clinically by abdominal ultrasound with Doppler flow, and treatment is detorsion with cholecystectomy. CASE REPORT A 57-year-old female presented to the emergency department with severe abdominal pain, bilious vomiting, and loose stools. An initial diagnosis of gastroenteritis was made, however, the patient did not respond to symptomatic treatment and continued having pain, nausea and vomiting. Abdominal ultrasound revealed signs of acute cholecystitis and the patient underwent an open cholecystectomy where the gallbladder was found to be black, gangrenous, and voluminous due to torsion. Detorsion and cholecystectomy were performed without any complications. CONCLUSIONS Gallbladder torsion is a rare entity of acute abdomen that can be fatal if not diagnosed and treated promptly. Gallbladder torsion should be a part of the differential diagnosis of any patient presenting with an acute abdomen and unusual symptoms of acute cholecystitis.

Unusual Pattern of Invasive Lobular Carcinoma Metastasis: A Case Report.

BACKGROUND Metastasis of breast cancer to the gastrointestinal (GI) tract is not common, however, invasive lobular carcinoma is more likely to metastasize to the GI tract than ductal carcinoma. The simultaneous metastasis of invasive lobular carcinoma to the GI tract and ovaries is an extremely uncommon presentation, which may mimic another rare entity that is peritoneal carcinomatosis secondary to breast cancer. Diagnosis of this entity is difficult as it can masquerade as a primary disease process instead of a secondary one. Treatment is even more difficult due to the sparsity of guidelines regarding this presentation. CASE REPORT A 58-year-old female with a history of invasive lobular carcinoma of the left breast treated 5 years prior to presentation with GI symptoms. Workup revealed a stenosis of the sigmoid colon; however, colonoscopy and biopsy did not show signs of malignancy. The patient was initially diagnosed with diverticulitis and given appropriate treatment which mildly improved her symptoms but did not eradicate them. Continued symptoms and failed attempts at diagnosis prompted the decision to perform an exploratory laparotomy which revealed metastasis of invasive lobular carcinoma to the sigmoid colon, appendix, and ovaries. CONCLUSIONS GI metastasis of breast cancer is a difficult entity to diagnose and treat. Concomitant metastasis to the GI tract and genitourinary system is even more challenging to diagnose and treat. These variable metastasis presentations of breast cancer indicate a need for more specific modalities for follow-up of breast cancer patients especially those with the invasive lobular subtype which tends to metastasize to unusual distant sites and present years after diagnosis and treatment of the primary disease.

A Rare Presentation of Gall Bladder Volvulus: A Case Report.

BACKGROUND Gall bladder volvulus is a rare clinical entity, with only around 500 cases reported in the literature. It is defined as the rotation of the gallbladder on its mesentery along the axis of the cystic pedicle, although cases of torsion of the gallbladder fundus itself have been reported. CASE REPORT A 78-year-old woman presented for severe right upper-quadrant abdominal pain that began acutely 3 days prior. Her pain was accompanied by nausea and vomiting. She also reported feeling chills. Abdominal X-ray revealed a 7-cm-diameter subhepatic opacity containing gas. Abdominal ultrasound and CT scan revealed a distended and displaced gallbladder located below the liver, in contact with the right kidney. Subsequently, open cholecystectomy was performed, and a distended, necrotic gallbladder was found twisted on its pedicle; thus, a gall bladder volvulus was diagnosed. CONCLUSIONS In our patient, the classic patient characteristics of an elderly thin female with kyphosis were present. However, the rest of the presentation was not typical of gallbladder volvulus due to the patient's delay in seeking treatment, and was representative of the necrotic phase of gallbladder torsion, in which the patient becomes ill-appearing, with fever and chills, with significant abdominal rigidity.