Gallbladder volvulus is a relatively rare condition in which there is a rotation of the gallbladder around the axis of the cystic duct and artery.

Clinical presentation

Symptoms are non-specific. There may be a sudden onset of epigastric or right upper quadrant pain, and vomiting, in contradistinction to a more insidious onset of similar symptoms with acute cholecystitis or intermittent symptoms as with biliary colic. Laboratory evaluations are often non-specific, and generally, symptoms are worse than the laboratory tests. If there is fever or leukocytosis, then acute cholecystitis may have developed.

Epidemiology

Gallbladder volvulus predominantly affects older people. One study found a median age of presentation of 77 years, with a female: male ratio of 4:1 ⁵.

Pathology

It has been observed in patients with significant weight loss, in which there is loss of the pericholecystic supporting fat. 

Complications are related to torsion with ensuing vascular compromise and resultant gallbladder ischemia. This can lead to gallbladder necrosis, perforation and biliary peritonitis.

Radiographic features

Ultrasound

• large floating gallbladder

• wall thickening

• gallbladder outside the normal anatomical fossa

CT

• massively distended gallbladder

• pericholecystic fluid 

• gallbladder outside the normal anatomical fossa

• change in anatomical orientation, from vertical to horizontal ³

• medially pointing gallbladder fundus

• indrawing of the vascular pedicle and surrounding fat (swirl sign) ⁴

• loss of enhancement

• abrupt tapering of cystic duct (beak sign)

Treatment and prognosis

Cholecystectomy is the preferred treatment.