ArticlePDF Available

Rare case report of acalculous cholecystitis: Gallbladder torsion resulting in rupture

SAGE Publications Inc
SAGE Open Medical Case Reports
Authors:

Abstract and Figures

Acalculous cholecystitis caused by gallbladder torsion is a rare condition. Only 500 cases have been reported since the first diagnosed case in 1898. We present the case of a 89-year-old woman with sudden onset of severe epigastric pain, radiating across her right costal margin, associated with nausea. Her abdomen was soft, mildly distended, Murphy’s negative but with epigastric tenderness and palpable mass. Computed tomography and ultrasound demonstrated significant acute cholecystitis, with the common bile duct measuring 7 mm. Due to the patients’ comorbidities, conservative treatment was initiated, until she was becoming increasing worse, so a laparoscopic cholecystectomy was performed. The operation revealed gallbladder torsion causing complete gallbladder necrosis and perforation with intraperitoneal biliary spillage. Gallbladder torsion should be a high differential if an elderly female patient presenting with sudden onset of abdominal pain, tender epigastric/right upper quadrant mass and a distended gallbladder on imaging. A laparoscopic cholecystectomy must be performed promptly to reduce the likelihood of gallbladder rupture and reduce the mortality and morbidity associated with this condition.
This content is subject to copyright.
https://doi.org/10.1177/2050313X18823385
SAGE Open Medical Case Reports
Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-
NonCommercial 4.0 License (http://www.creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction
and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages
(https://us.sagepub.com/en-us/nam/open-access-at-sage).
SAGE Open Medical Case Reports
Volume 7: 1 –3
© The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/2050313X18823385
journals.sagepub.com/home/sco
Introduction
Acalculous cholecystitis accounts for 2%–15% of acute
cholecystitis cases and is diagnosed as gallbladder inflam-
mation without evidence of gallstone cystic duct obstruc-
tion.1 Gallbladder torsion (GT) is a rare cause of acalculous
cholecystitis which was first diagnosed in 1898,2 with
approximately 500 cases reported since3 and an incidence of
0.1% in patients with acute cholecystitis.4 GT occurs more
commonly in elderly females and is associated with increased
morbidity and mortality if diagnosis is delayed.3 Here, we
report a case of an elderly female patient who was success-
fully treated for acute necrotising acalculous cholecystitis as
a result of GT.
Case presentation
A 89-year-old woman presented with sudden onset of severe
epigastric pain, radiating across her right costal margin
towards her back. The pain was associated with nausea but
no vomiting, bowels had opened the day before, no associa-
tion with food and no other symptoms. The patient had a
background medical history of a previous upper gastrointes-
tinal bleed, gastro-oesophageal reflux disease, hiatus hernia,
chronic constipation, hypertension and emphysema. She was
a non-smoker and non-drinker.
Physical examination revealed a mildly distended, soft
abdomen with normal bowel sounds, marked epigastric
tenderness and palpable mass in epigastrium; Murphy’s
negative. Vital signs were within normal limits and she was
afebrile. Blood biochemistry was essentially normal: bili-
rubin 5 µmol/L, alkaline phosphatase (ALP) 41 U/L,
gamma-glutamyl transferase (GGT) 31 U/L, alanine
transaminase (ALT) 15 U/L, aspartate transaminase (AST)
20 U/L, C-reactive protein (CRP) 2 mg/L, white cell count
(WCC) 11 × 109/L and lipase 18 U/L. Computed tomogra-
phy (CT) imaging revealed significant acute cholecystitis,
associated with a moderately dilated gallbladder (4.5 cm
diameter), thickened gallbladder wall, pericholecystic free
fluid and fat stranding (Figure 1). An upper abdominal
Rare case report of acalculous cholecystitis:
Gallbladder torsion resulting in rupture
Brielle Elizabeth Wood1, Jodie Trautman2, Nicholas Smith2
and Soni Putnis2
Abstract
Acalculous cholecystitis caused by gallbladder torsion is a rare condition. Only 500 cases have been reported since the first
diagnosed case in 1898. We present the case of a 89-year-old woman with sudden onset of severe epigastric pain, radiating
across her right costal margin, associated with nausea. Her abdomen was soft, mildly distended, Murphy’s negative but with
epigastric tenderness and palpable mass. Computed tomography and ultrasound demonstrated significant acute cholecystitis,
with the common bile duct measuring 7 mm. Due to the patients’ comorbidities, conservative treatment was initiated, until
she was becoming increasing worse, so a laparoscopic cholecystectomy was performed. The operation revealed gallbladder
torsion causing complete gallbladder necrosis and perforation with intraperitoneal biliary spillage. Gallbladder torsion should
be a high differential if an elderly female patient presenting with sudden onset of abdominal pain, tender epigastric/right upper
quadrant mass and a distended gallbladder on imaging. A laparoscopic cholecystectomy must be performed promptly to
reduce the likelihood of gallbladder rupture and reduce the mortality and morbidity associated with this condition.
Keywords
Gallbladder torsion, cholecystectomy, gallbladder rupture, acalculous cholecystitis, rare diseases
Date received: 8 July 2018; accepted: 13 December 2018
1Department of Surgery, Robina Hospital, Robina, QLD, Australia
2 Department of Surgery, Wollongong Hospital, Wollongong, NSW,
Australia
Corresponding Author:
Brielle Elizabeth Wood, Department of Surgery, Robina Hospital, Locked
Bag 15, Robina, QLD 4226, Australia.
Email: brielle.e.wood@gmail.com
823385SCO0010.1177/2050313X18823385SAGE Open Medical Case ReportsWood etal.
case-report2019
Case Report
2 SAGE Open Medical Case Reports
ultrasound done the following day revealed acute acalcu-
lous cholecystitis with the common bile duct measuring
7 mm in diameter, no intrahepatic duct dilatation and did
not report on blood flow.
Her ASA-PS (American Society of Anesthesiologist
Physical Status) score was III and CCI (Charlson comor-
bidity index) score was 5, which made her a high-risk sur-
gical candidate. Therefore, she was initially treated
conservatively as acute cholecystitis with intravenous
antibiotics, until day two post-admission she become
increasingly unwell and underwent a laparoscopic chole-
cystectomy. Operative findings were of a pedicled, supra-
hepatic gallbladder on a narrow cystic duct stalk which
appeared acutely torted with consequent complete gall-
bladder necrosis and perforation (Figure 2). Intraoperative
cholangiogram demonstrated normal biliary anatomy,
long cystic duct and nil dilation or filing defects.
Histopathology showed features of acute necrotising
cholecystitis, without gallstones, a large amount of haem-
orrhagic fluid in lumen and two areas of stricture in the
region of the gallbladder neck (19 and 34 mm from cystic
duct margin). The patient was discharged 5 days after the
operation.
Discussion
GT is a rare and potentially life-threatening condition if not
promptly diagnosed and treated. Since GT was first diag-
nosed in 1898,2 approximately 500 cases have been reported3
and occurs at a rate of 0.1% in patients diagnosed with acute
cholecystitis.4 GT is a result of the gallbladder becoming
pedunculated, with its only attachment to the liver by the
cystic mesentery; this phenomenon is referred to as ‘floating
gallbladder’.2
Figure 1. Computed tomography image demonstrating
significant acute cholecystitis, associated with a dilated and
thickened wall gallbladder plus pericholecystic free fluid and fat
stranding.
Figure 2. Intraoperative photo demonstrating gallbladder (GB) torsion and associated GB necrosis. Note position of GB situated upon
the diaphragmatic hepatic surface instead of within the GB fossa. Also note the thin and suspended GB pedicle which contained both the
cystic duct and artery, and which was the axis of torsion, thus producing resultant GB ischaemia.
Wood etal. 3
The gallbladder can rotate either clockwise or anticlock-
wise. The most common direction for torsion is clockwise and
is thought to be related to gastric (clockwise) or colonic (coun-
terclockwise) peristalsis.5 The degree of torsion determines the
severity of GT. Type I is less than 180 degrees, allowing limited
blood supply, and type II is more than 180 degrees, causing
complete obstruction.6 The gallbladder can undergo infarction,
gangrene and/or perforation, when blood supply is affected.
Case studies over the years have reported numerous risk
factors, signs, symptoms and investigations to help diagnose
GT. Elderly patients are at greater risk of the gallbladder
becoming separated from the liver, due to loss of visceral fat
and elasticity with increasing age.7 Clinical findings indica-
tive of GT include sudden onset of abdominal pain, early
emesis and tender mass in the right upper quadrant.8 When
comparing the biochemistry of acute cholecystitis and GT,
GT often has normal liver function and biliary enzyme but
elevated inflammatory markers.9 Preoperative imaging usu-
ally involves a CT scan demonstrating a distended gallblad-
der, with high attenuation and a circular structure to the right
of the gallbladder.10 GT can theoretically be ruled out if a
Doppler ultrasonography shows normal blood flow.11 A more
reliable diagnostic test is a magnetic resonance cholangio-
pancreatography (MRCP). The findings positive for GT
include gallbladder fundus towards the abdominal centre,
V-shaped extrahepatic duct and cystic duct torsion.5,9
Although we are aware of the above points of diagnosis, the
pre-operative diagnosis of GT is not commonly achieved and
is not diagnosed until a cholecystectomy is performed.
This case report demonstrates the importance of keeping the
differential diagnosis of a GT at the top of the list in an elderly
female with acalculous cholecystitis. In hindsight she had clini-
cal and radiological signs suggestive of GT, which could have
lead us to perform an MRCP for a prompter diagnosis. Early
diagnosis or suspicion of GT can lead to a more rapid definitive
treatment (cholecystectomy) and reduce the risk of the poten-
tially fatal sequel of gallbladder necrosis and perforation.
Conclusion
When a patient suffers from sudden onset of abdominal pain,
a tender epigastric mass and a distended gallbladder on
imaging, the differential diagnosis of GT must be kept in
mind to reduce morbidity and mortality. A laparoscopic chol-
ecystectomy must be performed promptly to reduce the like-
lihood of gallbladder rupture.
Acknowledgements
N.S. and S.P. oversaw the diagnosis and clinical care provided to
the patient. B.E.W., J.T. and N.S. performed the literature review
and wrote the manuscript. All authors read, edited and approved the
final manuscript.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship and/or publication of this article.
Ethical approval
Our institution does not require ethical approval for reporting indi-
vidual cases or case series.
Funding
The author(s) received no financial support for the research, author-
ship and/or publication of this article.
Informed consent
Informed consent was obtained from the patient for the publication
of this case report and accompanying images.
ORCID iD
Brielle Elizabeth Wood https://orcid.org/0000-0001-5854-4818
References
1. Treinen C, Lomelin D, Krause C, et al. Acute acalculous chol-
ecystitis in the critically ill: risk factors and surgical strategies.
Langenbecks Arch Surg 2015; 400(4): 421–427.
2. Wendel AV.VI. A case of floating gall-bladder and kidney
complicated by cholelithiasis, with perforation of the gall-
bladder. Ann Surg 1898; 27(2): 199–202.
3. Reilly DJ, Kalogeropoulos G and Thiruchelvam D. Torsion
of the gallbladder: a systematic review. HPB 2012; 14(10):
669–672.
4. Beliaev AM, Shapkov P and Booth M. Incidence of gallblad-
der torsion in acute cholecystectomy patients. ANZ J Surg
2015; 85(10): 793.
5. Garciavilla PC, Alvarez JF and Uzqueda GV. Diagnosis and
laparoscopic approach to gallbladder torsion and cholelithi-
asis. JSLS 2010; 14(1): 147–151.
6. Gross RE. Congenital anomalies of the gallbladder. Arch Surg
1936; 32: 131–162.
7. Matsuhashi N, Satake S, Yawata K, et al. Volvulus of the
gall bladder diagnosed by ultrasonography, computed tomog-
raphy, coronal magnetic resonance imaging and magnetic
resonance cholangio-pancreatography. World J Gastroenterol
2006; 12(28): 4599–4601.
8. Lau WY, Fan ST and Wong SH. Acute torsion of the gall blad-
der in the aged: a re-emphasis on clinical diagnosis. Aust N Z
J Surg 1982; 52(5): 492–494.
9. Izuishi K, Kiuchi T and Mori H. Education and imaging.
Hepatobiliary and pancreatic: gallbladder torsion diagnosed
by curved multi-planar reconstruction computed tomography.
J Gastroenterol Hepatol 2014; 29(4): 665.
10. Merine D, Meziane M and Fishman EK. CT diagnosis of
gallbladder torsion. J Comput Assist Tomogr 1987; 11(4):
712–713.
11. Lee SE, Choi YS and Kim BJ. Torsion of the gallbladder in
pregnancy. J Korean Surg Soc 2013; 85(6): 302–304.
... morbiditate semnificativă dacă nu este recunoscută prompt [5,6] și este descoperită frecvent accidental de către chirurg în timpul intervenției chirurgicale de urgență efectuate pentru o suspiciune de colecistita acută [5,[7][8][9][10]18]. Respectiv, până în prezent literatura de specialitate a fost limitată la câteva rapoarte de caz și serii de cazuri [5,7], în total fiind publicate aproximativ 500 de cazuri [1-10, 16, 18]. ...
... Aspect fiziopatologic. TVB se caracterizează prin torsiune organo-axială mecanică în sensul acelor de ceasornic sau în sens invers acelor de ceasornic de-a lungul axei longitudinale a vezicii biliare cu implicarea arterei și ductului cistice [8,16,18,19,21]. Conform datelor literaturii de specialitate, sunt determinate 5 variante anatomice de poziție a vezicii biliare în raport cu ficatul: ...
... Conform literaturii de specialitate TVB poate fi completă (>180°) sau parțială (<180°) [3,5,8,18,19,26,33]. Volvulus parțial poate fi diagnosticat greșit drept o colică biliară, în timp ce torsiunea completă produce durere severă acută în hipocondrul drept ce imită colecistita acută, iar în cazul dacă patologia nu este recunoscută prompt contribuie la necroza și perforația vezicii biliare [3,8,26,33]. ...
... morbiditate semnificativă dacă nu este recunoscută prompt [5,6] și este descoperită frecvent accidental de către chirurg în timpul intervenției chirurgicale de urgență efectuate pentru o suspiciune de colecistita acută [5,[7][8][9][10]18]. Respectiv, până în prezent literatura de specialitate a fost limitată la câteva rapoarte de caz și serii de cazuri [5,7], în total fiind publicate aproximativ 500 de cazuri [1-10, 16, 18]. ...
... Aspect fiziopatologic. TVB se caracterizează prin torsiune organo-axială mecanică în sensul acelor de ceasornic sau în sens invers acelor de ceasornic de-a lungul axei longitudinale a vezicii biliare cu implicarea arterei și ductului cistice [8,16,18,19,21]. Conform datelor literaturii de specialitate, sunt determinate 5 variante anatomice de poziție a vezicii biliare în raport cu ficatul: ...
... Conform literaturii de specialitate TVB poate fi completă (>180°) sau parțială (<180°) [3,5,8,18,19,26,33]. Volvulus parțial poate fi diagnosticat greșit drept o colică biliară, în timp ce torsiunea completă produce durere severă acută în hipocondrul drept ce imită colecistita acută, iar în cazul dacă patologia nu este recunoscută prompt contribuie la necroza și perforația vezicii biliare [3,8,26,33]. ...
Article
Full-text available
... Gallbladder torsion is difficult to diagnose [8], but if treated according to acute cholecystitis, an urgent situation can be avoided. However, in most cases like our first case, when the initial signs and symptoms were not clear likewise other acute cholecystitis, the operation could be delayed due to suspicion of another disease [9]. And in the majority of cases, the patient is older and has many underlying diseases, acalculous cholecystitis can be often managed non-operatively with a growing trend toward percutaneous cholecystostomy as the initial and sometimes definitive management [4]. ...
Article
Gallbladder torsion is a rare disease and it is very difficult to diagnose preoperatively because the signs, symptoms, and image findings are very similar to the other cases of acute cholecystitis. However, in cases of gallbladder torsion, conservative treatments such as intravenous antibiotics and percutaneous cholecystostomy could be ineffective and result in even fatal. Hence, for urgent surgical management, gallbladder torsion must be considered especially in the elderly female patients with radiologic findings such as acalculous cholecystitis and a free-floating gallbladder. The author presents two cases of necrotizing gallbladder torsion in an elderly female patient who was treated successfully with laparoscopic cholecystectomy.
... La teoría de la visceroptosis (4,8,9,10) es aplicable al caso presentado, en el cual durante el acto quirúrgico pudo observarse un mesenterio laxo, así como una rotación incompleta (mayor de 180 o ) de la vesícula sobre su eje, lo cual condicionó que no se presentaran signos macroscópicos de tipo isquémico. ...
Article
Full-text available
The case report of a 95 years patient is described, she went to the emergency department of Saturnino Lora Torres Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba due to a diffuse abdominal pain, of sudden beginning with 48 hours of clinical course, accompanied by nauseas and vomits of scarce quantity and dark color, as well as slight abdominal distention, without expulsion of stools neither gases. Her admission was decided for emergency surgical treatment, with the presumptive diagnosis of intestinal occlusion. During the surgery the distended gallbladder with bent pedicle was found. A typical cholecystectomy was carried out. The patient had a favorable clinical course and she didn't present postoperative complications.
Article
Full-text available
Introducción: El vólvulo de vesícula biliar (VVB) es una causa extremadamente rara de colecistitis aguda. Aproximadamente 500 casos han sido reportados en la literatura mundial. Puede generar una obstrucción total del drenaje vesicular e isquemia con alto riesgo de progresar a perforación y peritonitis biliar. Caso clínico: Mujer de 90 años consultó por dolor hipogástrico de inicio súbito, asociado a masa abdominal palpable y dolorosa en flanco y fosa ilíaca derecha. Tomografía axial computada de abdomen y pelvis demostró una acentuada distensión de la vesícula biliar, ubicada por fuera de la fosa vesicular y con un punto sugerente de torsión. Fue sometida a laparotomía exploradora, desvolvulación seguida de colecistectomía, con evolución posoperatoria favorable. Discusión: Para el desarrollo de un VVB se requiere una “vesícula flotante”, su cuadro clínico es inespecífico y muchas veces es confundido con una colecistitis aguda litiásica, su diagnóstico preoperatorio es difícil pese al estudio con imágenes. La intervención quirúrgica oportuna es el único tratamiento resolutivo, con excelentes resultados. Conclusión: La VVB es una patología rara, representa un desafío diagnóstico tanto para cirujanos como radiólogos.
Article
Full-text available
Introducción: El vólvulo de vesícula biliar (VVB) es una causa extremadamente rara de colecistitis aguda. Aproximadamente 500 casos han sido reportados en la literatura mundial. Puede generar una obstrucción total del drenaje vesicular e isquemia con alto riesgo de progresar a perforación y peritonitis biliar. Caso clínico: Mujer de 90 años consultó por dolor hipogástrico de inicio súbito, asociado a masa abdominal palpable y dolorosa en flanco y fosa ilíaca derecha. Tomografía axial computada de abdomen y pelvis demostró una acentuada distensión de la vesícula biliar, ubicada por fuera de la fosa vesicular y con un punto sugerente de torsión. Fue sometida a laparotomía exploradora, desvolvulación seguida de colecistectomía, con evolución postoperatoria favorable. Discusión: Para el desarrollo de un VVB se requiere una “vesícula flotante”, su cuadro clínico es inespecífico y muchas veces es confundido con una colecistitis aguda litiásica, su diagnóstico preoperatorio es difícil pese al estudio con imágenes. La intervención quirúrgica oportuna es el único tratamiento resolutivo, con excelentes resultados. Conclusión: La VVB es una patología rara, representa un desafío diagnóstico tanto para cirujanos como radiólogos.
Article
Full-text available
Background: Gallbladder torsion is a rare acute abdominal condition that requires emergency surgery. It occurs more commonly in elderly people and in women in the adult population. Diagnosis is a challenge as non-specific symptoms and signs have been reported on ultrasonography, computed tomography and magnetic resonance imaging. Prompt cholecystectomy can decrease the mortality and morbidity of perforation due to gallbladder torsion. Case summary: An 82-year-old woman with upper-right quadrant pain and associated nausea and vomiting was diagnosed with ectopic acute calculus cholecystitis. Magnetic resonance cholangiopancreatography (MRCP) showed a V-shaped distortion of the extrahepatic bile ducts and a particularly extended twisted cystic duct, which indicated the presence of gallbladder torsion. Emergency laparoscopic cholecystectomy confirmed the diagnosis and the patient recovered without incident. Conclusion: Gallbladder torsion can be diagnosed pre-operatively by MRCP. The specific signs are a V-shaped distortion of the extrahepatic bile ducts and a particularly extended twisted cystic duct which can be called twisting signs.
Article
Full-text available
Torsion of the gallbladder is a rare condition that is difficult to diagnose preoperatively, but prompt surgical intervention is necessary to avoid possible sepsis and death. A 36-year-old pregnant woman presented to Emergency Department with a constant epigastric pain at 17 weeks of gestation. Abdominal ultrasonography and magnetic resonance imaging demonstrated a distended gallbladder that contained no stones but had mild wall thickening. Laparoscopic cholecystectomy using three ports was performed under the impression of an acalculous cholecystitis. The gallbladder was found to be rotated 180 degrees clockwise on gallbladder mesentery and to be gangrenous. The postoperative course was uneventful and the patient was discharged on the 4th day after surgery. It is important to keep in mind gallbladder torsion in the differential diagnosis from acute cholecystitis when the patient has an acute onset of abdominal pain and a severely distended gallbldder. Prompt cholecystectomy via a laparoscopic approach should be performed.
Article
Full-text available
Torsion of the gallbladder is common in elderly women. Different causes have been proposed for this rare condition. The presence of a long mesentery and loss of visceral fat are the main causes for the development of torsion. Patients present with a sudden, acute pain in the right upper quadrant, suggesting cholecystitis. Different imaging methods have shown particular findings, but the diagnosis is still complex. Today, just a few cases have been reported in the literature. The treatment for this condition consists of surgical detorsion and cholecystectomy. Gallbladder torsion is a very rare entity and should be suspected when these clinical findings are present.
Article
Acute acalculous cholecystitis (AAC) is characterized by severe gallbladder inflammation without cystic duct obstruction. Critical illness and neurological deficits are often associated with AAC, and early radiologic imaging is necessary for the detection and timely treatment of AAC. In critically ill patients, effective surgical management is difficult. This review examines the three common surgical treatments for AAC (open cholecystectomy (OC), laparoscopic cholecystectomy (LC), or percutaneous cholecystostomy (PC)), their prevalence in current literature, and the perioperative outcomes of these different approaches using a large retrospective database. This review examined literature gathered from PubMed and Google Scholar to select more than 50 sources with data pertinent to AAC; of which 20 are described in a summary table. Outcomes from our previous research and several updated results were obtained from the University HealthSystem Consortium (UHC) database. LC has proven effective in treating AAC when the risks of general anesthesia and the chance for conversion to OC are low. In critically ill patients with multiple comorbidities, PC or OC may be the only available options. Data in the literature and an examination of outcomes within a national database indicate that for severely ill patients, PC may be safer and met with better outcomes than OC for the healthier set of AAC patients. We suggest a three-pronged approach to surgical resolution of AAC. Patients that are healthy enough to tolerate LC should undergo LC early in the course of the disease. In critically ill patients, patients with multiple comorbidities, a high conversion risk, or who are poor surgical candidates, PC may be the safest and most successful intervention.
Article
Background: Gallbladder torsion is a rare disease, predominantly affecting elderly women. It is an important differential in the acute surgical abdomen. Methods: A total of 324 published case reports of torsion of the gallbladder were reviewed. Features in diagnostic imaging suggestive of torsion were reviewed and summarized. Results: Gallbladder torsion is primarily a disease of elderly people; the median age at presentation is 77 years. It is more common amongst women, occurring at a female : male ratio of 4 : 1, although not in childhood, when it occurs at a male : female ratio of 2.5 : 1. Conclusions: Improved imaging techniques within the last 20 years have enabled the preoperative diagnosis of one quarter of patients with gallbladder torsion. With prompt surgical intervention, the condition has an excellent prognosis.
Article
We report a case in which CT led to the diagnosis of acute torsion of the gallbladder.
Article
Three cases of torsion of the gall bladder in the aged are presented. From a review of the clinical features of these cases and the cases reported in the literature, a definite clinical pattern emerged. The clinical features can be grouped into three triads: a triad of the patient's characteristics which consists of a thin, old patient with chronic chest disease or a deformed spine; a triad of symptoms which consists of typical abdominal pain, early onset of vomiting and a short history; and a triad of physical signs which consists of an abdominal mass, a lack of toxaemia or jaundice and a discrepancy in the pulse and temperature. If most, if not all, of these features are present, torsion of the gall bladder should be presented. We re-emphasize that a clinical suspicion or diagnosis of torsion of the gall bladder is possible. The treatment is early cholecystectomy.