Gallbladder perforation
Updates to Article Attributes
Gallbladder perforations are a relatively rare complication that can occur in a number of situations, but occur most common as a result of acute cholecystitis. It can carry a relatively high morality rate. It can also occur during laparoscopic cholecystectomies with the incidence of gallbladder perforation in this situation according to some reports estimated to occur as high as 15-30% 3.
Clinical presentation
Clinical presentation of can range from an acute generalised peritonitis to benign non-specific abdominal symptoms. Symptoms and clinical signs can be indistinguishable from those of uncomplicated acute cholecystitis 1.
Pathology
A perforation can occur as early as two days after the onset of acute cholecystitis, or can occur after several weeks. The sequence of events that leads subsequently to perforation is thought to result from occlusion of the cystic duct (most often by a calculus) with resultant retention of intra-luminal secretions. Distension of the gallbladder with a consequent rise in intraluminal pressure can impede venous and lymphatic drainage, leading to vascular compromise and ultimately to necrosis and perforation of the gallbladder wall.
Classification
According to the Niemeier classification the are three main clinical sub types 9:
- type I: acute free perforation
- type II: subacute pericholecystic abscess
- type III: chronic cholecystoenteric fistulation
Radiographic features
Ultrasound
Ultrasound is usually the initial investigation of choice. Reported findings include pericholecystic fluid collection(s) with layering of the gallbladder wall 8.
CT
CT is often considered superior to ultrasound in diagnosis and may show features of background cholecystitis with a visible defectin in the wall (or a bulge to suggest an occult defect 8) and evidence of bile leakage. CT will often also show a pericholecystic fluid collection, streaky omentum or mesentery +/- layering of the gallbladder wall 8.
Complications
Reported complications include 1, 6
- bile peritonitis
- hepatic abscess formation (possible mechanisms include direct extension, subcapsular extension and hematogenous dissemination via the portal vein)
- subhepatic abscess formation
- pelvic abscess formation
- pneumonia
- pancreatitis
- acute renal failure
-</ul><h4>Radiographic features</h4><h5>Ultrasound</h5><p>Ultrasound is usually the initial investigation of choice. Reported findings include <a title="pericholecystic fluid" href="/articles/pericholecystic-fluid">pericholecystic fluid collection(s)</a> with layering of the gallbladder wall <sup>8</sup>.</p><h5>CT</h5><p>CT is often considered superior to ultrasound in diagnosis and may show features of background cholecystitis with a visible defect <span style="line-height:20.7999992370605px">in the wall </span><span style="line-height:1.6">(or a bulge to suggest an occult defect </span><sup>8</sup><span style="line-height:1.6">) and evidence of bile leakage. CT will often also show a <a title="pericholecystic fluid" href="/articles/pericholecystic-fluid">pericholecystic fluid</a> collection, streaky omentum or mesentery +/- layering of the gallbladder wall</span><sup> 8</sup><span style="line-height:1.6">.</span></p><h4>Complications</h4><p>Reported complications include <sup>1, 6</sup></p><ul>- +</ul><h4>Radiographic features</h4><h5>Ultrasound</h5><p>Ultrasound is usually the initial investigation of choice. Reported findings include <a href="/articles/pericholecystic-fluid">pericholecystic fluid collection(s)</a> with layering of the gallbladder wall <sup>8</sup>.</p><h5>CT</h5><p>CT is often considered superior to ultrasound in diagnosis and may show features of background cholecystitis with a visible defect in the wall (or a bulge to suggest an occult defect <sup>8</sup>) and evidence of bile leakage. CT will often also show a <a href="/articles/pericholecystic-fluid">pericholecystic fluid</a> collection, streaky omentum or mesentery +/- layering of the gallbladder wall<sup> 8</sup>.</p><h4>Complications</h4><p>Reported complications include <sup>1, 6</sup></p><ul>
Image 5 Ultrasound ( create )
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