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Special Feature
June 2002

Image of the Month

Arch Surg. 2002;137(6):741-742. doi:
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.24 Although it is more commonly found in elderly patients, especially women, gallbladder volvulus has been described in all age groups.2,410

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.25,710

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.

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Article Information

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@emoryhealthcare.org).

References
1.
Wendel  AV A case of floating gallbladder and kidney complicated by cholelithiasis with perforation of the gallbladder. Ann Surg. 1898;27199- 202
2.
Lyons  KPChalla  SAbrahm  DKennelly  BM Floating gallbladder: a questionable prelude to torsion: a case report. Clin Nucl Med. 2000;25182- 183Article
3.
Alden  PBMiller  JBGamble  WG Volvulus of the gallbladder: report of two cases and review of the literature. Minn Med. 1989;72653- 656
4.
Van der Veken  EAzagra  JSde Prez  C Gallbladder volvulus: a case report. Acta Chir Belg. 1986;86267- 269
5.
McAleese  PKolachalam  RZoghlin  G Saint's triade presenting as volvulus of the gallbladder. J Laparoendosc Surg. 1996;6421- 425Article
6.
Taha  AMWelling  RE Acute torsion of the gallbladder in a 100-year-old female patient. J Natl Med Assoc. 1985;77404- 410
7.
Schroder  DMCusumano  DA  III Laparoscopic cholecystectomy for gallbladder torsion. Surg Laparosc Endosc. 1995;5330- 334
8.
Stieber  ACBauer  JJ Volvulus of the gallbladder. Am J Gastroenterol. 1983;7896- 98
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Losken  AWilson  BWSherman  R Torsion of the gallblladder: a case report and review of the literature. Am Surg. 1997;63975- 978
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McHenry  CRByrne  MP Gallbladder volvulus in the elderly: an emergent surgical disease. J Am Geriatr Soc. 1986;34137- 139
11.
Lau  WYFan  STWong  SH Acute torsion of the gallbladder in the aged: a re-emphasis on clinical diagnosis. Aust N Z J Surg. 1982;52492- 494Article
12.
Wellsted  MKam  JFunston  MR Radiological pointers to pre-operative diagnosis of torsion of the gallbladder: a case report. S Afr Med J. 1980;58980- 982
13.
Wang  GJColln  MCrossett  JHolmes  RA "Bulls-eye" image of gallbladder volvulus. Clin Nucl Med. 1987;12231- 232Article
14.
Carter  RThompson  RJBrennan  LP Volvulus of the gallbladder. Surg Gynecol Obstet. 1963;116105- 108
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Ashby  BS Acute and recurrent torsion of the gall-bladder. Br J Surg. 1965;52182- 184Article
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;32131- 162Article
17.
Brewer  GE Preliminary report on surgical anatomy of the gallbladder and ducts from an analysis of 100 dissections. Ann Surg. 1898;29721- 730
18.
Nguyen  TGeraci  ABauer  JJ Laparoscopic cholecystectomy for gallbladder volvulus. Surg Endosc. 1995;9519- 521Article
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