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Jeffrey M. Nicholas, MD, MS
From the Department of Surgery, Emory University School of Medicine, Atlanta, Ga.

Arch Surg. 2002;137:741-742.

INTRODUCTION
A 28-YEAR-OLD WOMAN, gravida 4, para 3, aborta 0 (35 weeks), presented with a 36-hour history of acute onset of postprandial right upper quadrant pain, nausea, and vomiting. She described similar episodes of this pain during the preceding month. Her physical examination was remarkable for right upper quadrant tenderness, but her temperature was 36.2°C and her white blood cell count was 7.1 x 10³/µL. Ultrasonography of her right upper quadrant showed a distended gallbladder with multiple stones, but results of liver function tests were normal.

The patient was treated conservatively for the presumed diagnosis of acute cholecystitis but became more symptomatic the next day. Initially, a laparoscopic approach was attempted, but because of perihepatic adhesions and the inability to visualize the gallbladder, the abdomen was opened and the findings in Figure 1 and Figure 2 were noted.

Figure 1.

Figure 2.

What Is the Diagnosis?

Jump to Section  • Top  • Introduction  • What is the diagnosis?  • Answer: gallbladder volvulus  • Author information  • References

A. Acute cholecystitis

B. Gallbladder volvulus

C. Acalculus cholecystitis

D. Hydrops of the gallbladder

Answer: Gallbladder Volvulus

Figure 1. Acute gangrenous cholecystitis.

Figure 2. Gallbladder volvulus demonstrating a free-floating gallbladder and twisting of the cystic artery and duct on a short mesentery. After rotating the gallbladder counterclockwise, a cholecystectomy was performed.

Wendel¹ initially described gallbladder volvulus (also called gallbladder torsion) in a 25-year-old pregnant patient in 1898. Since then, more than 300 cases have been reported.^2-4 Although it is more commonly found in elderly patients, especially women, gallbladder volvulus has been described in all age groups.^{2, 4-10}

Although patients typically present with acute onset of abdominal pain and have right upper quadrant tenderness, a palpable mass may be present in only 20% of patients and gallstones are found in only 20% to 50% of cases.^{7, 9} Lau et al¹¹ described 3 triads of clinical diagnosis, which include the physical characteristics (thin, elderly, and deformed spine); symptoms (short history, abdominal pain, and early vomiting); and physical signs (abdominal mass, absence of toxemia, and a pulse rate–temperature discrepancy).¹¹

Imaging studies may contribute to the diagnosis but are often nonspecific. The ultrasound examination may show a distended gallbladder with a square appearance but no gallstones.^{2, 12} A "bull's-eye" may be seen on the hepatobiliary nuclear scan, and delayed filling of the gallbladder may be seen on decubitus images.^{2, 13}

Anatomic variants of the peritoneal attachments between the gallbladder and the liver are present in all cases. These attachments create a "floating gallbladder" with a short mesentery containing only the cystic artery and duct, or a floating gallbladder with a long mesentery around which the gallbladder twists.^{2, 4, 6-7,12, 14} The gallbladder torsion may be complete (360°), resulting in gangrenous cholecystitis, or incomplete (180°), resulting in intermittent symptoms of biliary colic.¹⁵ The direction of torsion may be clockwise or counterclockwise, and both directions are found with equal frequency.^7-8 Autopsy studies have found these anatomic variants in up to 4% to 5% of the population; however, the incidence of gallbladder torsion is much lower.^16-17 Precipitating factors are common, eg, gastrointestinal peristalsis, kyphoscoliosis, visceroptosis, gallstones, cystic artery atherosclerosis, abdominal trauma, sudden motion, heavy meals, constipation, adhesions, weight loss, and postpartum status.^2-5,7-10

Although detorsion and pexis have been described, treatment remains to be cholecystectomy.¹⁵ Early diagnosis prevents perforation of a gangrenous gallbladder and should result in a surgical mortality of less than 5%.⁹ Laparoscopic cholecystectomy, as described by Nguyen et al¹⁸ and Schroder and Cusumano,⁷ is facilitated by decompression and untwisting of the gallbladder, which prevents injury to the common bile duct that may be tented up into the torsion.

AUTHOR INFORMATION

Jump to Section  • Top  • Introduction  • What is the diagnosis?  • Answer: gallbladder volvulus  • Author information  • References

Corresponding author and reprints: Jeffrey M. Nicholas, MD, MS, Department of Surgery, Room 308, Glenn Memorial Bldg, 69 Butler St SE, Atlanta, GA 30303 (e-mail: jeffrey_nicholas{at}emoryhealthcare.org).

REFERENCES

Jump to Section  • Top  • Introduction  • What is the diagnosis?  • Answer: gallbladder volvulus  • Author information  • References

1. Wendel AV. A case of floating gallbladder and kidney complicated by cholelithiasis with perforation of the gallbladder. Ann Surg. 1898;27:199-202. PUBMED 2. Lyons KP, Challa S, Abrahm D, Kennelly BM. Floating gallbladder: a questionable prelude to torsion: a case report. Clin Nucl Med. 2000;25:182-183. PUBMED 3. Alden PB, Miller JB, Gamble WG. Volvulus of the gallbladder: report of two cases and review of the literature. Minn Med. 1989;72:653-656. PUBMED 4. Van der Veken E, Azagra JS, de Prez C. Gallbladder volvulus: a case report. Acta Chir Belg. 1986;86:267-269. PUBMED 5. McAleese P, Kolachalam R, Zoghlin G. Saint's triade presenting as volvulus of the gallbladder. J Laparoendosc Surg. 1996;6:421-425. PUBMED 6. Taha AM, Welling RE. Acute torsion of the gallbladder in a 100-year-old female patient. J Natl Med Assoc. 1985;77:404-410. PUBMED 7. Schroder DM, Cusumano III DA. Laparoscopic cholecystectomy for gallbladder torsion. Surg Laparosc Endosc. 1995;5:330-334. PUBMED 8. Stieber AC, Bauer JJ. Volvulus of the gallbladder. Am J Gastroenterol. 1983;78:96-98. PUBMED 9. Losken A, Wilson BW, Sherman R. Torsion of the gallblladder: a case report and review of the literature. Am Surg. 1997;63:975-978. PUBMED 10. McHenry CR, Byrne MP. Gallbladder volvulus in the elderly: an emergent surgical disease. J Am Geriatr Soc. 1986;34:137-139. PUBMED 11. Lau WY, Fan ST, Wong SH. Acute torsion of the gallbladder in the aged: a re-emphasis on clinical diagnosis. Aust N Z J Surg. 1982;52:492-494. PUBMED 12. Wellsted M, Kam J, Funston MR. Radiological pointers to pre-operative diagnosis of torsion of the gallbladder: a case report. S Afr Med J. 1980;58:980-982. PUBMED 13. Wang GJ, Colln M, Crossett J, Holmes RA. "Bulls-eye" image of gallbladder volvulus. Clin Nucl Med. 1987;12:231-232. PUBMED 14. Carter R, Thompson RJ, Brennan LP. Volvulus of the gallbladder. Surg Gynecol Obstet. 1963;116:105-108. PUBMED 15. Ashby BS. Acute and recurrent torsion of the gall-bladder. Br J Surg. 1965;52:182-184. PUBMED 16. Gross RE. Congenital anomalies of the gallbladder: a review of one hundred and forty-eight cases, with report of a double gallbladder. Arch Surg. 1936;32:131-162. 17. Brewer GE. Preliminary report on surgical anatomy of the gallbladder and ducts from an analysis of 100 dissections. Ann Surg. 1898;29:721-730. 18. Nguyen T, Geraci A, Bauer JJ. Laparoscopic cholecystectomy for gallbladder volvulus. Surg Endosc. 1995;9:519-521. PUBMED

SECTION EDITOR: GRACE S. ROZYCKI, MD