Torsion of the gallbladder is a rare cause of cholecystitis. The incidence is estimated at 1 in every 365.520 hospital admissions.
1 The first case was described by Wendel in 1898.
2 It is a condition mainly seen in elderly women, and the incidence appears to increase with increased life expectancy.
3 Torsion of the gallbladder can only occur in patients with anatomic variation of gallbladder fixation to the liver. This could be a complete, but too long and wide mesentery or an incomplete mesentery covering only the cystic duct and artery. In these anatomic variations, there is a free-floating gallbladder. Another possibility is that relaxation and atrophy of a previously normal mesentery in the elderly cause visceroptosis.
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5 For the final torsion, a provocative moment is needed. In literature, kyphoscoliosis, forceful peristaltic movements, adhesions, atherosclerosis of the cystic artery, and sigmoid volvulus are reported as possible provocative factors.
6 Striking is that the patient in our case report had a kyphoscoliosis. Symptoms of gallbladder torsion are acute onset of abdominal pain, nausea, and vomiting. These symptoms can be intermitting in case of 180° torsion.
6 The often unusual location of a tordated gallbladder hampers making the right diagnosis and seldom is the diagnosis made before surgery. There are radiological signs that can indicate torsion of the gallbladder. Especially the presence of the gallbladder outside the normal anatomic fossa and a stretched cystic duct and gallbladder neck can indicate a free-floating gallbladder and are thereby risk factors for torsion of the gallbladder. Likewise, the absence of bile stones in a gallbladder with signs of cholecystitis can suggest a torsion of the gallbladder since an acalculous cholecystitis is very rare in otherwise healthy patients. A hypo-echogenic zone between the mucosa and serosa of the gallbladder is a sign of venous stasis and hematoma in the gallbladder wall.
7 Besides an abnormal location of the gallbladder, a swirl sign of the cystic duct can be seen on CT images. The gallbladder will be more distended in torsion than in a normal acute cholecystitis.
8 Treatment of a tordated gallbladder is acute (laparoscopic) cholecystectomy.
In conclusion, torsion of the gallbladder is a rare but clinical important condition in which the diagnosis is seldom made before surgery. At radiologic and clinical signs of acute cholecystitis in the absence of bile stones but with a free-floating gallbladder, this diagnosis must be considered.