The diagnostic dilemma of a gallbladder volvulus: An unusual case report and review of the literature.

INTRODUCTION AND IMPORTANCE: A gallbladder volvulus is a rare medical condition requiring emergency surgery. There are 500 cases reported in the literature, and only 10 % have ever been diagnosed preoperatively. Gallbladder volvulus occurs when the gallbladder torts around the cystic duct and cystic artery resulting in occlusion of both structures and consequently, ischemia of the gallbladder. The diagnosis is challenging because the symptoms mimic cholecystitis without distinct radiological features specific for a volvulus. CASE PRESENTATION: In this article, we report the case of a 77-year-old female who underwent ultrasonography (US), computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and cholescintigraphy, which all reported features of cholecystitis. She underwent a cholecystectomy on admission day 5 because of refractory pain despite treatment with intravenous antibiotics. Intraoperatively, she was discovered to have complete gallbladder torsion with gangrene. Post-operatively, she had immediate and complete resolution of pain, and made a rapid recovery. CLINICAL DISCUSSION: We review the available literature to determine radiological characteristics specific to a gallbladder volvulus. Patients without cholelithiasis and incomplete filling of the gallbladder in a nuclear medicine scan should be evaluated for gallbladder volvulus. CONCLUSION: Through this report, we suggest a high index of suspicion for gallbladder volvulus in elderly female patients with signs and symptoms of acalculous cholecystitis that have no resolution in symptoms with conservative management.

Cholinergic Modulation of Frontoparietal Cortical Network Dynamics Supporting Supramodal Attention.

A critical function of attention is to support a state of readiness to enhance stimulus detection, independent of stimulus modality. The nucleus basalis magnocellularis (NBM) is the major source of the neurochemical acetylcholine (ACh) for frontoparietal cortical networks thought to support attention. We examined a potential supramodal role of ACh in a frontoparietal cortical attentional network supporting target detection. We recorded local field potentials (LFPs) in the prelimbic frontal cortex (PFC) and the posterior parietal cortex (PPC) to assess whether ACh contributed to a state of readiness to alert rats to an impending presentation of visual or olfactory targets in one of five locations. Twenty male Long-Evans rats underwent training and then lesions of the NBM using the selective cholinergic immunotoxin 192 IgG-saporin (0.3 µg/µl; ACh-NBM-lesion) to reduce cholinergic afferentation of the cortical mantle. Postsurgery, ACh-NBM-lesioned rats had less correct responses and more omissions than sham-lesioned rats, which changed parametrically as we increased the attentional demands of the task with decreased target duration. This parametric deficit was found equally for both sensory targets. Accurate detection of visual and olfactory targets was associated specifically with increased LFP coherence, in the beta range, between the PFC and PPC, and with increased beta power in the PPC before the target's appearance in sham-lesioned rats. Readiness-associated changes in brain activity and visual and olfactory target detection were attenuated in the ACh-NBM-lesioned group. Accordingly, ACh may support supramodal attention via modulating activity in a frontoparietal cortical network, orchestrating a state of readiness to enhance target detection.SIGNIFICANCE STATEMENT We examined whether the neurochemical acetylcholine (ACh) contributes to a state of readiness for target detection, by engaging frontoparietal cortical attentional networks independent of modality. We show that ACh supported alerting attention to an impending presentation of either visual or olfactory targets. Using local field potentials, enhanced stimulus detection was associated with an anticipatory increase in power in the beta oscillation range before the target's appearance within the posterior parietal cortex (PPC) as well as increased synchrony, also in beta, between the prefrontal cortex and PPC. These readiness-associated changes in brain activity and behavior were attenuated in rats with reduced cortical ACh. Thus, ACh may act, in a supramodal manner, to prepare frontoparietal cortical attentional networks for target detection.

Cholinergic contributions to supramodal attentional processes in rats.

Cholinergic neurotransmission has been shown to play an important role in modulating attentional processing of visual stimuli. However, it is not yet clear whether the neurochemical acetylcholine (ACh) is necessary exclusively for visual attention, or if it also contributes to attentional functions through some modality-independent (supramodal) mechanism. To answer this question, we examined the effects of reduced cortical cholinergic afferentation on both a traditional visual and a novel olfactory five-choice serial reaction time task (5-CSRTT), the benchmark rodent test of sustained attention in rats. Following the successful acquisition of both modalities of the task, the rats underwent either a cholinergic immunotoxic- or sham-lesion surgery of the nucleus basalis magnocellularis (NBM), the basal forebrain nuclei that provide the majority of neocortical ACh. Reduced cholinergic afferentation to the neocortex was induced by bilaterally infusing the cholinergic immunotoxin 192 IgG-saporin into the NBM. After surgery, ACh-NBM-lesioned rats performed comparably to sham-lesioned rats under the conditions of low attentional demand, but displayed behavioral decrements relative to the sham-lesioned rats when the attentional demands of the task were increased. Moreover, this decrement in attentional functioning correlated significantly with the number of choline acetyltransferase-immunoreactive cells in the NBM. Importantly, the nature of this behavioral decrement was identical in the visual and olfactory 5-CSRTTs. Together, these data suggest the presence of a supramodal attentional modulatory cortical network whose activity is dependent on cholinergic innervation from the NBM.