Volvulus of the gallbladder.

A case of gallbladder volvulus is presented. This is a rare entity that most frequently affects elderly females. It is associated with anatomical variations relating to abnormal fixation of the gallbladder to the liver bed. Diagnosis is usually at laparotomy and early surgical treatment is essential. Cholecystectomy may be performed laparoscopically or as an open procedure. Gallbladder volvulus should be suspected in elderly patients with symptoms of acute cholecystitis CASE REPORT An 86-year-old-female presented with a sudden onset of right upper quadrant pain and vomiting. Abdominal examination revealed right upper quadrant tenderness and a palpable mass in the right hypochondrium. Preliminary haematological and biochemical tests were within normal limits. Chest and abdominal radiographs were also unremarkable. Initially she was treated expectantly. However within 24 hours of admission she developed signs of sepsis, with an associated leucocytosis and pyrexia. An ultrasound scan of abdomen (Fig.) Fig. Ultrasound of liver bed demonstrating gross gallbladder distension with gallstones and surrounding free fluid. demonstrated a grossly distended, oedematous gallbladder with evidence of cholelithiasis and surrounding free fluid. The patient was prepared for surgery. This revealed a grossly enlarged, necrotic gallbladder resulting from a 360 degree torsion of a pedicle containing the cystic artery and duct. Following detorsion, cholecystectomy was performed in combination with intra-operative cholangiography. The patient made an uneventful post-operative recovery. DISCUSSION The first description of gallbladder volvulus was by Wendel in 1898.1 Since then over 300 cases have been reported in the literature." 2The peak incidence of this condition is between 60 and 80 years2' 3with a 3:1 female predominance.3 Gallbladder volvulus has also been reported in children and young adults,2 one patient being as young as two years of age.4 Normally the gallbladder is closely attached to the under-surface of the liver. For an organ to twist, it must have a mesentery with a relatively short base compared to its length.' Two anatomical variants exist which allow gallbladder torsion; visceroptosis with mesenteric elongation and the "free-floating" gallbladder I of which there are two types, one with a mesentery and one with a pedicle containing the cystic artery, vein and duct.6 Between 4 and 5% of the population have