Gallbladder perforations are a relatively rare complication that occur most frequently as a result of acute cholecystitis, with a relatively high mortality.
Clinical presentation can range from benign non-specific abdominal symptoms to an acute generalised peritonitis. Symptoms and clinical signs can be indistinguishable from those of an uncomplicated acute cholecystitis 1.
A perforation can occur as early as two days after the onset of acute cholecystitis or as long as several weeks after. 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 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.
It may also occur during laparoscopic cholecystectomies with the incidence of gallbladder perforation in this situation estimated to be 15-30% 3.
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 usually the initial investigation of choice. Reported findings include pericholecystic fluid collection(s) with layering of the gallbladder wall 8.
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 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.
Treatment and prognosis
Gallbladder perforation may be initially treated with a percutaneous cholecystostomy. It can carry a relatively high mortality rate.
Reported complications include 1,6:
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