PMC5055938_01
(a), (b), and (c) show computed tomography axial images of the abdomen with the gallbladder marked by (*). Notice the different anatomical positions of the gallbladder over a six-year period. (d), (e), and (f) show computed tomography coronal images of the abdomen showing changes in the anatomical position of the gallbladder (blue arrow); the choledochal cyst (red arrow) is shown to be increasing in size over the same period.
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A computed tomography (CT) scan demonstrated a markedly dilated extrahepatic biliary ductal system (intrapancreatic common bile duct > 2.5 cm) and a markedly distended gallbladder (Figure 1). After reviewing of previous CT scans spanning several years, the gallbladder was noted to be located in several different locations adding suspicion for gallbladder torsion to the differential diagnosis (Figure 1).
An MRCP image is shown in (a), demonstrating the type 1C choledochal cyst (red arrow), in addition to the distended, torsed gallbladder (blue arrow). Notice the severe narrowing of the gallbladder infundibulum as it joins the dilated bile duct (arrowhead). (b) is an ERCP cholangiogram demonstrating the choledochal cyst without distal common bile duct stricture or stone. The gallbladder did not opacify with contrast due to cystic duct obstruction.
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The extrahepatic bile duct had a fusiform dilation measuring 27 mm in the largest dimension (Figure 2).
An intraoperative photograph showing the severe distention and discoloration of the gallbladder. This was observed upon entry into the abdomen, the gallbladder was found to be torsed around the cystic duct and cystic artery (shown next to the instrument tip), and there was no other attachment between the gallbladder and the liver.  Figure 2(b) shows the gallbladder after it was opened on the back table; no gallstones were found. There was a significant gallbladder wall thickening and necrosis.
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The gallbladder was readily removed following simple ligation of the cystic artery and duct (Figure 3). Inspection of the specimen revealed significant gallbladder wall thickening and absence of gallstones (Figure 3).