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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: jeffrey_nicholas@emoryhealthcare.org).