Gallbladder Volvulus

Etiology

Gallbladder volvulus is a rare condition in which the gallbladder twists around its mesentery. This pathology is believed to result from anomalies in the anatomy of the gallbladder's vascular pedicle or an abnormally long gallbladder mesentery, allowing the gallbladder to float freely. As a result, the gallbladder is at risk of twisting around the axis of the cystic duct and artery. Age-related loss of visceral fat contributes to the higher incidence of gallbladder volvulus in older adults. Other contributing factors include peristaltic activity of the surrounding bowel, spinal deformities, and the presence of a tortuous atherosclerotic cystic artery.[5][6]

Epidemiology

Gallbladder volvulus has been reported across various age groups, but it is most common in older adults, particularly women in their 70s and 80s. The condition occurs in women 3 times more frequently than in men. Mortality associated with gallbladder volvulus is approximately 6%.[7]

Pathophysiology

Gallbladder torsion is an acute condition that occurs when the gallbladder twists around elongated mesenteric tissue along the axis of the cystic duct and artery. The presence of gallstones is neither a prerequisite nor a contributor to this condition. Instead, gallbladder volvulus is believed to result from organoaxial rotation, which compromises the gallbladder’s blood supply, leading to ischemia, necrosis, and obstruction of biliary drainage. Aging increases the gallbladder’s tendency to hang freely, making it more susceptible to torsion.

Gallbladder torsion can be classified as either complete or incomplete. A rotation greater than 180° is considered complete, while a rotation of less than 180° is considered incomplete.

History and Physical

Patients with gallbladder volvulus often present to the emergency department with abdominal pain that may localize to the epigastrium or right upper quadrant (RUQ), although diffuse abdominal pain has also been reported. The symptoms may resemble those of recurrent biliary colic if the torsion is incomplete. In contrast, complete torsion typically presents with sudden-onset, severe RUQ pain accompanied by vomiting. A palpable abdominal mass may sometimes be felt, while jaundice and signs of toxemia are often absent.

Preoperative diagnosis of gallbladder torsion is challenging due to nonspecific symptoms and signs, which can resemble those of acute infectious conditions. Clinical findings may also mimic acute appendicitis or ischemic bowel. Regardless of the direction of rotation, the blood supply is compromised, leading to infarction and gangrene. Patients are often admitted with a presumptive diagnosis of infection and are treated with resuscitation and antibiotics. However, persistent symptoms despite appropriate management for acute right-sided abdominal pathology should prompt a high level of suspicion for gallbladder volvulus.

Evaluation

The preoperative diagnosis of gallbladder torsion remains challenging for surgeons and radiologists despite the availability of advanced laboratory investigations and imaging. Liver function tests are often inconclusive in cases of incomplete volvulus, and both cell count and C-reactive protein levels may be elevated.

Ultrasonography is typically the first imaging modality used in suspected cases of gallbladder torsion. The 3 key ultrasonographic features indicative of this condition include a diffusely thickened, hypoechoic gallbladder wall suggestive of gangrene and inflammation; a "floating" gallbladder, where much of the organ is detached from the liver bed; and a conical structure at the gallbladder neck, characterized by multiple linear echoes converging toward the tip of the "cone."[8][9]

Ultrasonography and computed tomography (CT) are the primary imaging techniques for diagnosing gallbladder torsion. CT scans may reveal a "floating gallbladder" with wall thickening, while magnetic resonance imaging (MRI) can identify a twisted cystic duct. T2-weighted MRI images are particularly useful for assessing gallbladder wall necrosis. Accurate interpretation of imaging findings is essential for confirming the diagnosis.

A hepatobiliary iminodiacetic acid (HIDA) scan, if utilized, may display a characteristic bullseye pattern caused by radioisotope accumulation in the gallbladder. Early diagnosis of gallbladder torsion is critical to prevent severe complications, including gallbladder gangrene, perforation leading to bilious peritonitis, and abdominal infections. Timely management can significantly reduce morbidity and mortality, prevent complications, and lower hospitalization costs.[10][11]

Upper gastrointestinal endoscopy can assist in diagnosing gallbladder torsion. Diagnostic findings may include distortion of the proximal gastric anatomy and challenges in intubating the stomach and pylorus. Endoscopy may reveal frank mucosal sloughing, ulceration, or necrosis in advanced stages.

Treatment / Management

A diagnosis or suspicion of acute gallbladder volvulus requires urgent surgical intervention. Emergent cholecystectomy, performed via either an open or laparoscopic approach, is the procedure of choice. The crucial steps include decompression and derotation of the gallbladder to clearly visualize the anatomical structures. Careful dissection of the anatomical structure is critical, as torsion often results in abnormal positioning of biliary structures, such as the common bile duct, increasing the risk of iatrogenic injury. Prompt surgery yields excellent outcomes, while delays can lead to gallbladder infarction, necrosis, and bilious peritonitis, significantly raising morbidity and mortality rates.

Differential Diagnosis

The differential diagnosis of gallbladder volvulus includes conditions presenting with RUQ pain or acute abdomen symptoms, such as:

• Acute or chronic cholecystitis
• Biliary colic
• Biliary neoplasm
• Mirizzi syndrome
• Choledochal cyst
• Ileosigmoid knot
• Pseudoobstruction
• Severe constipation
• Right-sided diverticular disease

Careful clinical and diagnostic examination are essential to distinguish gallbladder volvulus from these pathologies. Maintaining a high index of suspicion facilitates timely surgical intervention and appropriate management.

Prognosis

Early diagnosis and timely surgical intervention lead to a favorable prognosis for gallbladder volvulus. Delayed treatment, however, increases the risk of gallbladder necrosis and peritonitis, significantly worsening outcomes. Prompt surgical management minimizes the risk of severe complications and enhances the likelihood of full recovery without lasting adverse effects.

Complications

If left untreated, gallbladder volvulus can result in severe complications, including infarction, necrosis, and bilious peritonitis, all of which can be life-threatening. Delayed intervention also increases the risk of postoperative issues, such as infection, bile leakage, and adhesions, which can further hinder recovery and increase the risk of morbidity.