Twist of Fate: Diagnosing and Managing Gallbladder Volvulus in an Elderly Patient.

Gallbladder volvulus (GV) is a rare surgical emergency characterized by the twisting of the gallbladder around its mesentery, leading to vascular compromise and gangrene. It is often misdiagnosed as acute gangrenous cholecystitis due to overlapping symptoms, making preoperative diagnosis challenging. Definitive identification is typically made intraoperatively. Contributory factors include advanced age, female gender, low body mass index, and increased gallbladder mobility. Urgent surgical intervention is crucial to prevent severe complications such as perforation and biliary peritonitis. We report a case of an elderly woman with a low BMI who had a history of right hemicolectomy for locally advanced cecal cancer and ongoing immunotherapy for pelvic recurrence. She presented with acute epigastric pain, nausea, and vomiting but no fever or jaundice. Examination revealed a tender upper abdomen with a palpable mass. Laboratory investigations showed leucocytosis with unremarkable CRP, liver, and renal function tests. A CT scan demonstrated a grossly distended midline gallbladder with a swirl sign at the cystic pedicle, consistent with GV. Supportive management was given, followed by urgent laparoscopic cholecystectomy. Intraoperatively, a gangrenous gallbladder twisted 360° twice around its mesentery was identified and safely removed without complications. The patient made an uneventful recovery and was discharged within 48 hours. This case underscores the diagnostic challenges of GV and highlights the importance of a high index of suspicion, particularly in elderly, frail patients with risk factors. Imaging findings such as the "swirl sign" and midline crossing of the gallbladder on CT scan aid preoperative diagnosis. Urgent surgical intervention remains the cornerstone of management, as delayed treatment can result in significant morbidity.