Chronic Hypermobile Gallbladder: An Indication for Cholecystectomy

Abstract

Background

A hypermobile, or "wandering," gallbladder is defined by its sole attachment to the biliary system via the cystic duct and its mesentery, lacking any adhesion to the gallbladder fossa of the liver. This predisposes the gallbladder to excessive movement within the peritoneal cavity, potentially leading to torsion (twisting along its luminal axis) or volvulus (twisting along its mesenteric axis). While gallbladder torsion secondary to excess mesentery or liver atrophy is well-documented, torsion due to a wandering gallbladder is exceedingly rare, with fewer than ten reported cases. These cases often present with an acute abdomen due to ischemia, infection, or perforation.

Summary

We present a case of a patient with chronic, right upper quadrant pain, nausea, and diarrhea of several years' duration. Standard workup for biliary colic and cholecystitis—including ultrasound, MRCP, HIDA scan, serum biliary markers, and CT—was negative for gallbladder disease. A repeat CT scan revealed gallbladder contraction and borderline gallbladder wall thickening, potentially attributable to normal physiological variation.

However, given the patient's severe, chronic symptoms suggestive of gallbladder dysfunction, an elective robotic-assisted laparoscopic cholecystectomy was performed. Intraoperatively, the gallbladder exhibited minimal attachment to the liver, limited to the gallbladder neck region and involving less than 25% of the gallbladder's length.

Furthermore, the inferior liver margin displayed fibrotic changes adjacent to the small gallbladder attachment, consistent with mechanical trauma from the freely mobile gallbladder. Postoperatively, the patient reported immediate and sustained resolution of right upper quadrant pain and gastrointestinal symptoms at both the two- and six-week follow-up appointments.

Conclusion

We propose that gallbladder hypermobility resulted in intermittent torsion, causing the patient's chronic pain and gastrointestinal symptoms. This case supports the consideration of elective cholecystectomy based on compelling clinical findings, even in the absence of an acute abdomen and negative diagnostic imaging and functional studies.

Key Words

gallbladder; torsion; hypermobile; cholecystectomy

Abbreviations

Case Description

Hypermobile gallbladder, also known as "wandering gallbladder," is a rare condition characterized by a gallbladder secured only by its mesentery and the cystic duct, lacking any attachments to the gallbladder fossa of the liver.¹ True wandering gallbladder is extremely rarely reported, with about 10 cases reported in the available literature.²

Even lesser degrees of hypermobility can predispose the gallbladder to torsion (rotation around the luminal axis) and volvulus (rotation around the mesenteric axis), potentially leading to perforation and sepsis.^1,3–5 An estimated 4-5% of the population has anatomical variations in the biliary system that may predispose to gallbladder torsion, including abnormalities such as an extended cystic duct and loose hepatic attachment.⁶ However, symptomatic gallbladder torsion is significantly less common, with an estimated prevalence of 1 in 365,520 hospital admissions.³

The classic presentation of gallbladder torsion involves a "triple triad" of symptoms (short history, abdominal pain, and early vomiting), physical signs (abdominal mass, absence of toxemia, and pulse-temperature discrepancy), and patient characteristics (typically thin, elderly individuals with spinal deformity).^6–10 Much of the existing literature on gallbladder torsion focuses on acute torsion, which more often results from age-related mesenteric atrophy than congenital biliary anomalies and typically presents as an acute abdomen. Intermittent gallbladder torsion due to hypermobility has been suggested as a cause of chronic biliary colic, including right upper quadrant pain and transient hyperbilirubinemia, although readily available case reports documenting these findings are scarce.^1,11,12

A 43-year-old Caucasian man presented to the general surgery clinic at Promedica Charles and Virginia Hickman Hospital with chronic intermittent right upper quadrant (RUQ) pain and nausea of several years' duration, which had recently increased in frequency. He described the pain as severe and radiating to his back. Following referral from his primary care provider, he underwent extensive gastroenterological evaluation, including normal blood work (bilirubin, liver enzymes, and white blood cell count), RUQ ultrasound showing hepatic steatosis, esophagogastroduodenoscopy revealing a small hiatal hernia and gastritis (without Helicobacter pylori), and dilated duodenal lacteals (without evidence of celiac disease). Abdominal CT and MRCP imaging were unremarkable, failing to identify a cause for his pain, and a HIDA scan demonstrated a normal gallbladder ejection fraction of 80%.

Between his last gastroenterology visit and his initial surgical consultation, the patient presented to the emergency department with abdominal pain. A repeat abdominal CT scan was performed, again showing no clear cause for the pain, but noting a contracted gallbladder with possible mild wall thickening. He was subsequently referred to general surgery for evaluation and management of his abdominal pain and potential gallbladder pathology.

At his initial surgical visit, the patient requested an elective cholecystectomy, hoping the findings from his recent CT scan (contracted gallbladder with possible mild wall thickening) would justify surgical intervention. His pain was significantly impacting his daily activities and had not responded to conservative management. Physical examination revealed a soft, non-distended, and non-tender abdomen. He denied systemic symptoms and presented without jaundice. Despite the absence of classic imaging or laboratory findings suggestive of chronic cholecystitis, and after multiple discussions regarding the uncertainty of symptom resolution following cholecystectomy, the patient opted to proceed with the procedure given the chronicity and severity of his symptoms. He understood the risks and benefits and requested the surgery. Informed consent was obtained, and the patient was scheduled for an elective robotic-assisted multiport laparoscopic cholecystectomy.

Following standard sterile preparation and draping, the patient was anesthetized and the peritoneal cavity entered. The gallbladder was grasped and retracted superiorly and laterally, and subsequently, the infundibular portion was grasped and retracted inferiorly and laterally (Figure 1). The gallbladder was noted to be mildly thickened and attached to the liver fossa only at a small area of the neck near the cystic duct, allowing the body and fundus to move freely within the abdominal cavity.

Figure 1. Intraoperative View of Gallbladder. Published with Permission

Notably, fibrosis was observed along the liver capsule adjacent to the gallbladder fundus. This fibrosis, distinct from any evidence of hepatic steatosis, appeared consistent with mechanical trauma to the liver resulting from the gallbladder's free movement. Cholecystectomy was completed without complications, utilizing 10 mm Hem-o-lok clips for cystic artery and cystic duct occlusion. The postoperative course was uneventful, and the patient was discharged the same day. Pathological examination of the gallbladder revealed chronic cholecystitis without cholelithiasis.

Two weeks postoperatively, the patient reported complete resolution of abdominal pain and nausea. Standard postoperative pain and bloating had resolved, and he no longer required pain medication. Incisions were well-healed without signs of infection. At a six-week follow-up, the patient remained asymptomatic and was discharged from surgical follow-up with instructions to return if symptoms recurred. Over the subsequent six months, during routine follow-up with his primary care physician, the patient reported no abdominal pain or gastrointestinal complaints.

Discussion

Gallbladder torsion, initially described by AV Wendel in 1898, presents a diagnostic and therapeutic challenge. Wendel's initial report detailed a young woman with abdominal pain, gastrointestinal symptoms, and a palpable abdominal mass,¹⁴ ultimately found to have a gangrenous, perforated, and torsed gallbladder. This case also represents the first documented instance of a hypermobile, or "wandering," gallbladder. In the 120 years since, true wandering gallbladder remains exceedingly rare, with only approximately ten reported cases.

Gallbladder torsion, while more common than wandering gallbladder, is still a relatively infrequent occurrence, with approximately 500 cases documented since Wendel's initial description. The majority of these cases describe gallbladder torsion in the context of an acute abdomen, highlighting the critical need for prompt recognition and surgical intervention, given the reported mortality rates of 5-6%.^15,16

Acquired changes in mesentery or liver morphology due to aging are the most frequent contributors to gallbladder torsion. However, congenital anomalies of the biliary tree anatomy can also predispose patients to this condition, as described in several studies.^5,17

There are three main categories of congenital anomalies that predispose the gallbladder to torsion:

• Freely Mobile Gallbladder: In this presentation, the gallbladder is attached to the liver only by the cystic duct and artery, lacking the usual supporting structures. This significantly increases the risk of volvulus.

• Gallbladder with Elongated Mesentery: This variant mirrors age-related mesenteric atrophy and organ ptosis, where the supporting tissues that hold the gallbladder in place become weak and stretched. This increased mobility makes the gallbladder more susceptible to torsion.
• Gallbladder Attached to a Wandering Liver: An exceptionally rare anomaly, this presentation involves a "wandering" liver not securely positioned within the abdomen, allowing for excessive movement. This instability can also affect the gallbladder's position and contribute to torsion.

In the present case, the gallbladder, while not attached by an elongated mesentery, exhibited a significantly smaller-than-normal area of attachment to the liver, resulting in excessive gallbladder mobility. This anatomical presentation most closely resembles the second category, although the comparison is imperfect. This may suggest the need for further refinement in the classification of these structural anomalies predisposing to gallbladder torsion.

The patient's presentation of right upper quadrant pain and nausea, coupled with the intraoperative findings of a minimally attached gallbladder and liver fibrosis, strongly suggest chronic intermittent gallbladder torsion secondary to gallbladder hypermobility as the etiology of her abdominal pain. Prior reports of gallbladder torsion predominantly describe acute presentations in elderly females, often accompanied by signs of perforation and sepsis.^3,6–8,10 While gallbladder torsion in younger patients is less common, these cases suggest a higher proportion of torsion resulting from age-related mesenteric changes rather than congenital anomalies.^{1,4,5,14,17,18}

Although Carter described chronic intermittent gallbladder volvulus and torsion as potential causes of chronic cholecystitis,¹¹ contemporary case reports of this specific phenomenon are scarce. A single recent case described a patient with a 3-year history of chronic right upper quadrant pain with a one-day exacerbation, ultimately found to have a 180-degree gallbladder torsion intraoperatively.¹⁹ However, the patient's demographics (elderly woman with a history of gallstones and fulfilling at least five of the nine characteristics in the "triple triad") suggested a presentation more consistent with chronic gallstone cholecystitis experiencing an acute exacerbation due to newly developed torsion.

In contrast to acute gallbladder torsion, which would likely manifest with abnormal imaging findings (e.g., enlarged gallbladder or thickened wall on ultrasound, disrupted duct lumen on MRCP or CT), the chronic intermittent torsion suspected in this case may elude detection due to its transient nature. The patient could experience symptomatic episodes of torsion or excessive gallbladder excursion, but these episodes might be too brief to elevate serum biliary markers or induce gallbladder wall inflammation discernible by ultrasound. This could explain the patient's chronic symptoms of gallbladder dysfunction in the absence of positive findings on diagnostic studies. The resolution of the patient's symptoms following cholecystectomy further supports this hypothesis.

Conclusion

To our knowledge, this case represents the first reported instance of chronic cholecystitis secondary to intermittent torsion of a hypermobile gallbladder in the absence of cholelithiasis or acute abdominal symptoms, successfully treated with cholecystectomy. The intraoperative finding of an unrestricted gallbladder body and fundus explains the patient's chronic right upper quadrant pain and nausea, presumably exacerbated with each episode of gallbladder folding or twisting. The observed liver capsule fibrosis surrounding the cystic duct insertion further supports the presence of a hypermobile gallbladder, capable of repeated movement and impact against the liver. Postoperative symptom resolution reinforces this hypothesis and provides additional support for surgical intervention in suspected cases of gallbladder torsion.

Lessons Learned

Consistent with previous reports on gallbladder torsion, we recommend a low threshold for cholecystectomy in patients with a clinical picture of chronic cholecystitis, especially after other differential diagnoses have been ruled out by extensive negative workup. This patient endured persistent symptoms for years despite undergoing various imaging studies, lab tests, and functional evaluations. Thankfully, he did not experience an acute complication from torsion during this time. Had the gallbladder torsion become fixed, rather than spontaneously resolving, acute complications, including gallbladder necrosis and perforation with associated poor outcomes, would have been highly probable.

Therefore, we emphasize the importance of comprehensive clinical history in patients with symptoms of gallbladder dysfunction and suggest the continued consideration of surgical intervention in the absence of confirmatory diagnostic studies, especially when a high index of suspicion for intermittent torsion exists.

Authors

Pasquinelly AC^a; Diep D^a,b

Author Affiliations

1. University of Toledo College of Medicine and Life Sciences, Toledo, OH 43614
2. ProMedica Charles and Virginia Hickman Hospital, Adrian, MI 49221

Corresponding Author

Adam C. Pasquinelly
University of Toledo
College of Medicine and Life Sciences
3000 Arlington Avenue
Toledo, OH 43614
Email: adam.pasquinelly@rockets.utoledo.edu

Meeting Presentation

Toledo Surgical Society Medical Student Research Competition, Toledo, OH, September 2022

Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding/Support

The authors have no relevant financial relationships or in-kind support to disclose.

Received: October 6, 2022
Revision received: February 1, 2023
Accepted: March 27, 2023

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