Gallbladder volvulus in an elderly patient presenting as acute calculous cholecystitis: a case report

Abstract

Introduction and importance:

Gallbladder volvulus is a rare, life-threatening emergency resulting from torsion of the gallbladder on its vascular pedicle. Its rarity and clinical similarity to acute cholecystitis make diagnosis difficult. This is the first documented case in the Philippines, highlighting its significance for local surgical practice.

Presentation of case:

A 74-year-old woman presented with acute right upper quadrant pain, nausea, vomiting, and bloating. Laboratory workup revealed leukocytosis with neutrophilia, and imaging suggested acute calculous cholecystitis. At surgery, complete 360° torsion of the gallbladder was confirmed. Cholecystectomy revealed a necrotic gallbladder with intraluminal stones. The patient recovered uneventfully and was discharged on postoperative day 3.

Clinical discussion:

Gallbladder volvulus is frequently misdiagnosed because of its nonspecific clinical, laboratory, and imaging features. Preoperative diagnosis is rarely achieved, with most cases confirmed intraoperatively. Prompt recognition and surgical intervention are crucial to prevent complications such as gangrene, perforation, and peritonitis. This report emphasizes the importance of considering gallbladder volvulus in elderly women with biliary symptoms not fully explained by imaging.

Conclusion:

Early suspicion, timely diagnosis, and urgent cholecystectomy are essential for favorable outcomes. This case highlights the need to increase clinical awareness of gallbladder volvulus in the Philippines to improve patient outcomes.

Introduction

Gallbladder volvulus (GV) presents as acute abdominal pain with nonspecific signs and symptoms^[1^]. It is the twisting of the gallbladder on its cystic duct attributed to the elongated gallbladder mesentery, with an incidence reported to be 1 in 365 520 hospital admissions^[2,3^].

The condition predominantly affects elderly women and is frequently misdiagnosed as acute cholecystitis due to overlapping clinical features, nonspecific laboratory findings, and imaging results^[1^]. Delayed recognition can lead to gallbladder ischemia, necrosis, or perforation, underscoring the importance of early surgical intervention.

HIGHLIGHTS

• First documented case of gallbladder volvulus in the Philippines, misdiagnosed as acute calculous cholecystitis.

• Demonstrates the diagnostic challenge posed by nonspecific labs and imaging.

• Intraoperative discovery of complete 360° torsion underscores the importance of surgical exploration.

• Case emphasizes need for heightened suspicion in elderly women with biliary symptoms.

• Early cholecystectomy is lifesaving and prevents gangrene or perforation.

This report describes the first documented case of GV locally. It aims to raise awareness of this rare entity as a differential diagnosis in patients presenting with biliary symptoms and to review the current literature on its early diagnosis, surgical management, and outcomes. This case report has been reported in line with the SCARE criteria^[4^].

Case presentation

Patient information

A 74-year-old female presented with acute onset of right upper quadrant abdominal pain, colicky in character, with a pain score of 6–7/10, associated with nausea, vomiting, and abdominal bloating. Worsening of symptoms prompted initial admission. She had a history of treated pulmonary tuberculosis and total abdominal hysterectomy with bilateral salpingo-oophorectomy in 1985. The patient had no other comorbidities.

Physical examination

On examination, the patient was hemodynamically stable and afebrile, with no jaundice. Abdominal assessment revealed focal direct tenderness in the right upper quadrant and a positive Murphy’s sign, with no palpable masses. Acute calculous cholecystitis was suspected.

Diagnostics

Laboratory tests revealed mild leukocytosis with neutrophilic predominance (WBC 11.7 × 10⁹/L, neutrophils 91%), with otherwise normal renal function, coagulation profile, and electrolytes. Liver enzymes showed mild elevation of serum glutamic pyruvic transaminase (67.73 U/L). Fasting blood sugar was slightly elevated at 8.09 mmol/L. Imaging with abdominal ultrasound and contrast-enhanced CT demonstrated a distended hydropic gallbladder (105 mL) with multiple stones (0.1–0.3 cm) and thickened walls (Fig. 1).

Figure 1.

Triple contrast whole abdomen CT scan in portal venous phase with representative (A) coronal, (B) sagittal, and (C) axial slices demonstrating a hydropic, distended gallbladder (red outline).

Therapeutic intervention

The patient was started on intravenous antibiotics, and laparoscopic cholecystectomy was planned. Intraoperatively, dense omental adhesions and a gangrenous gallbladder with dark pericholecystic fluid consistent with hemorrhage from the necrotic gallbladder were encountered (Fig. 2). Due to the unusual presentation and limited experience with this condition, the surgical team decided to convert to open surgery. Upon conversion, the gallbladder was noted to be completely free from the cystic plate, with a >180° torsion along its vascular pedicle at the cystic duct and artery (Fig. 3). Detorsion of the gallbladder was performed. The cystic pedicle lacked the usual fatty tissue, and the cystic artery was not skeletonized due to gangrenous changes, with underlying structures appearing edematous. Cholecystectomy was then carried out in the standard fashion, with careful ligation of the cystic duct at its origin from the common bile duct, ensuring safe dissection despite the inflamed tissues.

Figure 2.

Intraoperative photo of a gangrenous gallbladder (asterisk) floating on a pool of dusky pericholecystic fluid, with peritoneal adhesions.

Figure 3.

Intraoperative picture (A) showing point of torsion (tip of Debakey forceps). Gallbladder post-detorsion (B) revealing the cystic duct and compromised vascular pedicle.

Follow-up and outcomes

The patient’s postoperative course was unremarkable. She was discharged on post-operative day 3 and reported no symptoms during her 7-day post-operative follow-up. Subsequent follow-up 1 month after surgery revealed and unremarkable postoperative course with good wound healing. No further long-term follow-ups were feasible due to geographic and financial concerns. A chronological summary of the patient’s clinical course, diagnostic workup, and management is presented in Table 1.

Table 1.

Summary of the clinical course of the patient from symptom onset to post-operative follow-up.

Day	Clinical course
−4	Onset of worsening right upper quadrant pain, nausea, vomiting, and bloating
−3 to 0	Initial admission and work-up
0	Referral to institution, diagnosis of acute calculous cholecystitis confirmed
1	Surgery performed
2–3	Post-operative monitoring and recovery
10	Follow-up visit

Patient perspective

The patient expressed relief following the surgical intervention knowing the possible life-threatening complications that could have arisen had surgery not been expedited. She is reassured and grateful to be free of any health concerns.

Discussion

GV, or gallbladder torsion, is a rare surgical condition first described by Wendel in 1898^[1,2^]. It is defined as the rotation of the gallbladder along its mesentery or vascular pedicle, specifically the cystic duct and cystic artery. The gallbladder mesentery is composed of peritoneal folds that suspend the gallbladder from the inferior surface of the liver, extending along the cystic duct and artery. Normally, these peritoneal adhesions tether or stabilize the gallbladder in place. However, in patients with an elongated or “floating” gallbladder mesentery or for patients with a long cystic duct or a cystic duct with low insertion into the common bile duct, these attachments become lax, allowing abnormal mobility of the gallbladder^[2^] (Fig. 4). This predisposes the organ to torsion in a clockwise or counterclockwise direction^[4,5^]. Furthermore, GV can also be classified by the degree of rotation – incomplete (≤180°) or complete (>180°)^[6^]. However, data remain limited, and these anatomical configurations have not been definitively linked to incidence rates.

Figure 4.

Diagram showing (A) normal gallbladder versus (B) anatomical variant showing a freely suspended, floating or hanging gallbladder that may twist on its own axis resulting in gallbladder volvulus^[7^].

GV is more common in elderly women, typically between the sixth and eighth decades, with a female-to-male ratio of approximately 3:1^[8,9^]. Several risk factors contribute to the development of torsion, including loss of visceral fat, visceroptosis or downward displacement of abdominal organs, liver atrophy, spinal deformities, cachexia, and atherosclerosis of the cystic artery. Additional mechanical or hormonal factors – such as forceful peristaltic movements, adhesions, trauma, or increased cholecystokinin release – may precipitate torsion^[2,3^].

Clinically, GV mimics acute cholecystitis, presenting with right upper quadrant pain, nausea, vomiting, and sometimes a palpable mass. Unlike typical cholecystitis, patients may remain afebrile and hemodynamically stable, with normal or mildly deranged laboratory values^[1^]. This explains why the diagnosis is rarely made preoperatively; only about 10% of cases are identified before surgery^[4^].

Imaging with ultrasound, CT, or MRI can suggest gallbladder torsion, typically showing a (1) distended, floating gallbladder, (2) thickened walls or reduced wall enhancement, (3) pericholecystic fluid, (4) abnormal orientation or displacement of the gallbladder from its normal anatomic fossa, and (5) abrupt tapering of the cystic duct. Some subtle signs also include a horizontally oriented gallbladder, conical neck and a displaced cystic duct which may also be present but are often overlooked^[3,5,10–13^]. Magnetic resonance cholangiopancreatography is considered the preferred imaging modality for diagnosing GV^[7^].

From a surgical perspective, detorsion followed by cholecystectomy is the definitive treatment. In cases with gangrene, care must be taken during dissection, as the cystic pedicle may lack normal fatty tissue and underlying structures may be edematous. Ligation of the cystic duct at its origin from the common bile duct remains the standard approach^[8,9^]. Laparoscopic management is feasible, but conversion to open surgery may be warranted in cases with dense adhesions, inflamed or gangrenous gallbladder, or when visualization is limited. There is no available data comparing postoperative outcomes of laparotomy vs. laparoscopy for GV^[7^].

GV often presents incidentally during surgery for presumed cholelithiasis or cholecystitis, raising questions about whether certain high-risk patients might benefit from earlier surgical intervention. In elderly patients with risk factors (e.g., elongated mesentery, loss of visceral fat, spinal deformities), even isolated right upper quadrant pain with cholelithiasis – absent leukocytosis or hemodynamic instability – may warrant a lower threshold for cholecystectomy. While the absolute risk of volvulus is low, the potential for rapid progression to gangrene and perforation supports careful consideration in surgical decision-making, particularly in centers where intraoperative diagnosis may be the first opportunity to identify torsion^[1^].

Conclusion

• GV is a rare but potentially life-threatening cause of right upper quadrant pain, most common in elderly women with anatomic risk factors.

• Preoperative diagnosis is challenging due to nonspecific symptoms and imaging; suspicion should be higher in patients with clinical risk factors such as loss of visceral fat or visceroptosis, elongated gallbladder mesentery, etc.

• Prompt surgical intervention – laparoscopic or open cholecystectomy – is essential to prevent complications such as necrosis, gangrene, and perforation.

• Awareness of anatomical features such as GB mesentery anatomy and cystic duct variations can aid surgeons to anticipate complications during cholecystectomy.

• In high-risk elderly patients with cholelithiasis and isolated right upper quadrant pain, a lower threshold for surgery may be justified as this subset of patients may harbor torsion-prone gallbladders, although data on prophylactic indications remain limited.

Ethical approval

Ethics approval obtained from University of the Philippines Ethics Review Board.

Consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Sources of funding

No external sources of funding were required for this study.

Author contributions

P.A.R.G.: Study concept and writing the paper. A.R.P.: Writing and editing the paper and literature review. P.V.B.L.: Writing and editing and study design. O.C.B.: Writing and editing and data collection M.E.C.P.: Writing and editing.

Conflicts of interest disclosure

No conflict of interest identified.

Research registration unique identifying number

Not appliable.

Guarantor

Anthony R. Perez.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

All data relevant to this case report are included within the article. No additional datasets were generated or analyzed. Further information may be made available by the corresponding author upon reasonable request.