Gallbladder perforations are a relatively rare complication that can occur in some situations but occurs most frequently as a result of acute cholecystitis. It can carry a relatively high mortality 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 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.
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 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.
According to the Niemeier classification, there are three main clinical subtypes 9. A fourth type is 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 a 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
Reported complications include 1, 6
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