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Images in Surgery

Mysterious Gallbladder

A 71 year old female patient presented to the Emergency Department with diffuse abdominal pain in the right hemiabdomen with increasing intensity over the course of a few days, and a history of digestive issues. 

Case description:

Previous medical history proved unremarkable except for prior episodes of acute diverticulitis, osteoporosis, and a right bundle branch block. Blood work showed no gross abnormalities. Bilirubin was minimally elevated at 20 umol/l. In addition, the patient presented with a leucocytosis of 14.9 x 10*9/l without elevation in C reactive protein (CRP). Cardiac enzymes were also unremarkable. Due to the nonspecific nature of the patients symptoms, an ultrasound examination was performed. Here, no cholecystolithiasis was present, however some thickening of the gallbladder wall was observed (Figure A).

The appendix and ovaries could not visualized. No free fluid was found in the abdominal cavity. Without a clear diagnosis, the decision was made to observe the patient on the surgical ward over the course of 24 hours. The following day, the patient complained of further pain, this time focused in the mid to lower right abdomen. The physical examination showed a defense in the right lower quadrant. In addition, elevated inflammatory values were observed in the blood. The CRP had increased to 109 mg/l, with leucocytosis of 10.9 x 10*9/l. In addition, the bilirubin had also increased to 44 umol/l. After deliberation, the patient was prepped for same day surgery. A diagnostic laparoscopy was performed.


Figure A

What was the most likely intraoperativ diagnosis?

A.    Acute appendizitis

B.    Acute cholecystitis

C.     Ovarian torsion

D.    Gallbladder volvulus

E.     Gallbladder malignancy

Case Solution:

Intraoperatively, the gallbladder appeared to have rotated around the cystic duct and artery, with signs of ischemia (Figure B). A gallbladder volvulus was diagnosed and laparoscopic cholecystectomy was performed. The postoperative course was uneventful and the patient discharged at the third hospital day.

Gallbladder volvulus is a rare condition1. First described in 1898 as a „floating gallbladder, it occurs when the gallbladder twists around its mesentery2-4. This can be due to a long mesentery or an abnormality of the vascular pedicle5-6. Other contributing factors include the loss of visceral fat, as can occur with weight loss or aging7. Based on this, epidemiologically it shows two peaks3. Its relatively nonspecific clinical and diagnostic presentation complicates its diagnosis and can lead to delays in treatment. However, it presents an important differential diagnosis which must be considered as it can rapidly progress to septicemia due to the resultant ischemia and necrosis8.  


Figure B: intraoperative situs


1.     Yokoi T, Miyata K, Yuasa N, et al.: Twisted cystic artery disclosed by 3-dimensional computed tomography angiography for torsion of the gallbladder. Am J Surg. 2011, 201:e33-4. 10.1016/j.amjsurg.2010.04.026

2.     Lau WY, Fan ST, Wong SH: Acute torsion of the gall bladder in the aged: a re-emphasis on clinical diagnosis. Aust N Z J Surg. 1982, 52:492-4. 10.1111/j.1445-2197.1982.tb06036.x

3.     Reilly DJ, Kalogeropoulos G, Thiruchelvam D: Torsion of the gallbladder: a systematic review. HPB (Oxford). 2012, 14:669-72. 10.1111/j.1477-2574.2012.00513.x

4.     Pottorf BJ, Alfaro L, Hollis HW: A clinician's guide to the diagnosis and management of gallbladder volvulus. Perm J. 2013, 17:80-3. 10.7812/TPP/12-118

5.     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, 32:131-62. 10.1001/archsurg.1936.01180190134008

6.     Nadeem G: A study of the clinico-anatomical variations in the shape and size of gallbladder. J Morphol Sci. 2018, 33:062-7. 10.4322/jms.082714

7.     Boer J, Boerma D, de Vries Reilingh TS: A gallbladder torsion presenting as acute cholecystitis in an elderly woman: a case report. J Med Case Rep. 2011, 5:588. 10.1186/1752-1947-5-588

8.     Keeratibharat N, Chansangrat J (March 21, 2022) Gallbladder Volvulus: A Review. Cureus 14(3): e23362. DOI 10.7759/cureus.23362

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