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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.
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: firstname.lastname@example.org).
Image of the Month. Arch Surg. 2002;137(6):741–742. doi:
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