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Gallbladder perforations are a serious complication of acute cholecystitis and represent an advanced stage of the disease. They tend to occur in an elderly and/or comorbid demographic and carry higher rates of morbidity and mortality.
Symptoms and clinical signs are variable and can range from benign non-specific abdominal symptoms to acute generalized peritonitis.
The presentation of gallbladder perforation can be indistinguishable from uncomplicated acute cholecystitis 1.
Gallbladder perforation is the result of acute cholecystitis. The sequence of events leading to perforation begin with occlusion of the cystic duct (most often by a calculus), with resultant retention of intraluminal 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.
Regarding the timing of onset, perforation can between two days to several weeks after the onset of acute cholecystitis.
Perforation often occurs iatrogenically during laparoscopic cholecystectomy, with an incidence of estimated to be 15-30% 3. It can also rarely occur from blunt or penetrating trauma.
According to the Niemeier classification, there are three main clinical subtypes 9. A fourth type has been suggested by Andersen et al. 10.
- type I: acute free perforation
- type II: subacute pericholecystic abscess
- type III: chronic cholecystoenteric fistulation
- type IV: cholecystobiliary fistula formation
Ultrasound is the initial investigation of choice. Reported findings include pericholecystic fluid collection(s) with layering of the gallbladder wall 8.
CT is often superior to ultrasound for diagnosis of complications of acute cholecystitis.
Superimposed on background cholecystitis, CT may show:
- defect or bulge in the gallbladder wall
- focal bulge may suggest an occult defect 8
- pericholecystic fluid collection - evidence of bile leakage
- stranding of the omentum or mesentery
- +/- layering of the gallbladder wall 8
Treatment and prognosis
Gallbladder perforation may be initially treated by percutaneous cholecystostomy. Patients typically require intravenous antibiotics, volume resuscitation, and close monitoring in an intensive care unit. Eventually (if possible), cholecystectomy is performed 6.
Given that gallbladder perforation represents an advanced stage of acute cholecystitis, typically occurring in otherwise comorbid patients, the prognosis is often worse. Although very high mortality rates of ~40% were initially reported in the 1940s, contemporary literature cites a mortality rate between 12-16% 6.
Reported complications include 1,6:
- 1. Morris BS, Balpande PR, Morani AC et-al. The CT appearances of gallbladder perforation. Br J Radiol. 2007;80 (959): 898-901. doi:10.1259/bjr/28510614 - Pubmed citation
- 2. Vansonnenberg E, D'agostino HB, Casola G et-al. Gallbladder perforation and bile leakage: percutaneous treatment. Radiology. 1991;178 (3): 687-9. Radiology (abstract) - Pubmed citation
- 3. Morrin MM, Kruskal JB, Hochman MG et-al. Radiologic features of complications arising from dropped gallstones in laparoscopic cholecystectomy patients. AJR Am J Roentgenol. 2000;174 (5): 1441-5. AJR Am J Roentgenol (full text) - Pubmed citation
- 4. Ong CL, Wong TH, Rauff A. Acute gall bladder perforation--a dilemma in early diagnosis. Gut. 1991;32 (8): 956-8. Gut (link) - Free text at pubmed - Pubmed citation
- 5. Shukla RM, Roy D, Mukherjee PP et-al. Spontaneous gall bladder perforation: a rare condition in the differential diagnosis of acute abdomen in children. J. Pediatr. Surg. 2011;46 (1): 241-3. doi:10.1016/j.jpedsurg.2010.09.043 - Pubmed citation
- 6. Derici H, Kara C, Bozdag AD et-al. Diagnosis and treatment of gallbladder perforation. World J. Gastroenterol. 2006;12 (48): 7832-6. World J. Gastroenterol. (link) - Pubmed citation
- 7. Ergul E, Gozetlik EO. Perforation of gallbladder. Bratisl Lek Listy. 2008;109 (5): 210-4. - Pubmed citation
- 8. Kim PN, Lee KS, Kim IY et-al. Gallbladder perforation: comparison of US findings with CT. Abdom Imaging. 19 (3): 239-42. - Pubmed citation
- 9. Swayne LC, Filippone A. Gallbladder perforation: correlation of cholescintigraphic and sonographic findings with the Niemeier classification. J. Nucl. Med. 1990;31 (12): 1915-20. J. Nucl. Med. (link) - Pubmed citation
- 10. Anderson BB, Nazem A. Perforations of the gallbladder and cholecystobiliary fistulae: a review of management and a new classification. J Natl Med Assoc. 1987;79 (4): 393-9. Free text at pubmed - Pubmed citation