Question: A 76-year-old Caucasian woman presented from a nursing home to the local emergency department with a 1-day history of intense left iliac fossa pain on a background of 1-week history of diarrhea, nausea and vomiting, and no bowel action for 2 days. Her past medical history includes anemia, intellectual impairment, osteoarthritis, kyphoscoliosis, and a right hip arthroplasty. On examination, she was afebrile, her pulse rate was 110 (regular), and blood pressure was 133/61 mmHg with oxygen saturations of 96% on 2 liters of oxygen per minute. She was physically wasted with a body mass index of 19.12 kg/m2. There was a tender, mobile, central abdominal mass detected on deep palpation. Her hemoglobin was 134 g/L (normal, 110–160) and white cell count was 39.1 × 109/L (normal, 4–11 × 109/l) with a predominant neutrophilia. Urea, electrolytes, and creatinine were normal. Liver function tests were unremarkable aside from a bilirubin of 33 μmol/L (normal, <20). Chest x-ray revealed a raised right hemidiaphragm with clear lung fields. Abdominal x-ray was unremarkable. Computed tomography (CT) was performed (Figure A), which demonstrated a 9.5 × 5.8 × 6.7 cm (transverse × AP × craniocaudal), fluid-filled, central abdominal mass with tapering toward the right upper quadrant. A nuclear medicine scan (Figure B) confirmed the diagnosis, before the patient undergoing appropriate operative intervention. Look on page 1126 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. This patient had torsion of the gallbladder leading to gangrenous acute cholecystitis and underwent laparoscopic cholecystectomy (Supplementary Video). Gallbladder torsion is a rare condition whose true incidence is unknown. Approximately 500 cases of gallbladder torsion have now been documented since it was first described by Wendel in 1898.1Wendell A.V. A case of floating gall-bladder and kidney complicated by cholelithiasis with perforation of the gall-bladder.Ann Surg. 1989; 27: 199-202Google Scholar A condition associated with the elderly, it is believed to be of increasing incidence owing to the aging of the population. However, there are few recorded cases of gallbladder torsion being surgically resected laparoscopically since this was first reported in 1994,2Nguyen T. Geraci A. Bauer J. Laparoscopic cholecystectomy for gallbladder volvulus.Surg Endosc. 1994; 9: 519-521Google Scholar despite the condition being very amenable to this form of surgery. The CT films showing a floating abdominal mass combined with a hepatobiliary iminodiacetic acid scan in which gallbladder filling was not visualized, allowed a preoperative diagnosis of gallbladder torsion to be made and enabled adequate planning for and execution of a laparoscopic resection. In particular, the procedure was facilitated by intraoperative drainage of the grossly distended gallbladder. This patient portrays many of the classic characteristics and risk factors of a patient with torsion of the gallbladder. Lau et al3Lau W.Y. Fan S.T. Wong S.H. Acute torsion of the gallbladder in the aged: a re-emphasis on clinical diagnosis.Aust N Z J Surg. 1982; 52: 492-494Crossref PubMed Scopus (29) Google Scholar describes the “triad of triads” exhibited by patients with torsion of the gallbladder. The first triad is based on the patient's symptoms includes a short history of symptoms, right upper quadrant pain and early vomiting. The second triad relates to the patients physical signs: a palpable abdominal mass, the absence of toxemia and jaundice, and a pulse rate/temperature discrepancy. The final triad refers to potential risk factors for gallbladder torsion, namely, low body mass index, advanced age, and deformed spine. This case demonstrates all 9 of the noted stigmata. In addition to these risk factors, this patient also had a large hiatal hernia and a raised right hemidiaphragm that further altered her intraabdominal anatomy and may have predisposed her to this condition. The histopathology report of the specimen showed gangrenous necrotizing cholecystitis (Figures C and D). The patient recovered well and was discharged 4 days postoperatively without complication. Download .mpg (11.68 MB) Help with mpg files Supplementary Video