Gallbladder Volvulus

Author: Alan A Saber, MD, MS, FACS, FASMBS; Chief Editor: John Geibel, MD, DSc, MA more...

Updated: Jan 6, 2012

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Background
Problem
Epidemiology
Etiology
Pathophysiology
Presentation
Indications
Relevant Anatomy
Contraindications
Show All

Background

Torsion of the gallbladder is a condition in which the organ twists on its long axis to an extent that its vascular supply is compromised.^{[1, 2]}

Problem

Gallbladder volvulus was recognized in the late 19th century. This condition remains a rare entity that seldom is diagnosed preoperatively. It is encountered most frequently in patients who are fragile and elderly. A delay in the diagnosis and treatment may result in life-threatening consequences.

Frequency

Between 1898, when Wendell first described gallbladder volvulus, and the early 21st century, only about 300 cases of gallbladder torsion had been reported. The incidence appears to have increased, however, possibly because of an increase in life expectancy. Eighty-four percent of patients with gallbladder volvulus are elderly women. The peak incidence occurs in persons aged 65-75 years.

Etiology

Two anatomic variants of the gallbladder might undergo torsion. In one type, the gallbladder has a mesentery that is prone to torsion.^[3]In the other type, the mesentery supports only the cystic duct, allowing a completely peritonealized gallbladder to hang freely. Intermediate forms with a partial mesentery of the gallbladder and a mesentery of the cystic duct also are described.

In adults, a mesentery of the gallbladder can be acquired. The more frequent occurrence of torsion in elderly persons may be explained by the loss of fat and the atrophy of the tissues that may occur with advancing age, leaving the gallbladder hanging freely.

The precipitating factors for the final event of torsion have been cited as violent movements, including intense peristalsis of the neighboring organs, kyphoscoliosis of the spine, visceroptosis, and tortuous atherosclerotic cystic artery. The role of gallstones is debatable. Approximately 20-33% of patients with torsion have gallstones. Intense peristalsis of the stomach or the duodenum has been implicated in clockwise rotation, whereas the transverse colon is implicated in counterclockwise rotation.

Pathophysiology

Torsion of the gallbladder can be complete (ie, >180°) or incomplete (ie, < 180°). Complete torsion of a mobile gallbladder on its pedicle interferes with the blood supply to the organ, and if this condition is unrelieved, gangrene develops.

Presentation

The clinical features of gallbladder volvulus can be grouped into 3 triads. Patients who characterize the first triad are elderly, thin, and suffering from a deformed spine.^[3]The second triad consists of right upper quadrant abdominal pain, early onset of vomiting, and a short history of symptoms. The third triad of signs includes an abdominal mass, a lack of toxemia or jaundice, and discrepancies in pulse and temperature. Incomplete torsion usually is associated with recurrent episodes of slowly progressive pain, while complete torsion has an acute presentation.

Indications

Torsion of the gallbladder should be treated by prompt cholecystectomy.

Relevant Anatomy

See Etiology.

Contraindications

Operative intervention is necessary to avoid a fatal outcome due to nonresected gallbladder volvulus.

Proceed to Workup

Contributor Information and Disclosures

Author

Alan A Saber, MD, MS, FACS, FASMBS Associate Professor of Surgery, Case Western Reserve University School of Medicine; Director of Metabolic Surgery, Case Medical Center

Alan A Saber, MD, MS, FACS, FASMBS is a member of the following medical societies: American College of Surgeons, American Society for Gastrointestinal Endoscopy, and American Society for Metabolic and Bariatric Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Raul J Rosenthal, MD, FACS, FASMBS Professor of Surgery, Chairman, Section of Minimally Invasive Surgery and The Bariatric and Metabolic Institute, Program Director, Fellowship in Minimally Invasive Surgery, Herbert Wertheim School of Medicine, Florida International University

Raul J Rosenthal, MD, FACS, FASMBS is a member of the following medical societies: American College of Surgeons, American Society for Metabolic and Bariatric Surgery, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Oscar Joe Hines, MD Assistant Professor, Department of Surgery, University of California at Los Angeles School of Medicine

Oscar Joe Hines, MD is a member of the following medical societies: Alpha Omega Alpha, American Association of Endocrine Surgeons, American College of Surgeons, Association for Academic Surgery, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: RFA Medical None Director; MRC Biotec None Director

Paolo Zamboni, MD Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

Additional Contributors

The editors wish to acknowledge Danny Rosin, MD, Instructor, Department of General Surgery and Transplantation, Sheba Medical Center, Tel Hashomer, Israel, for his previous association with this article.

References

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