Gallbladder perforation: A rare case report

Abstract

Introduction

Gallbladder perforation (GBP) is a rare but severe, often fatal, disease due to its delayed pathology, demanding urgent surgical intervention. GBP can result from acute cholecystitis in 6–12 % of cases. It manifests in a variety of presentations. The diagnosis is frequently postponed or missed.

Case presentation

A 68-year-old woman came to the emergency department with the chief complaint of abdominal pain for 1 week. The pain began in the epigastric region and right upper abdominal quadrant, then extended to the whole abdomen. Abdominal bowel sounds were decreased, with muscular defense and tenderness throughout the abdomen. On rectal touch examination, the sphincter was loose. Laboratory tests found leukocytosis and hyperglycemia. An abdominal ultrasound examination showed cholelithiasis, sludge, and little echo fluid in the lower right abdomen.

Clinical discussion

The patient was diagnosed with generalized peritonitis and cholelithiasis with sepsis (qSOFA score 2; SOFA score 2). An emergency exploratory laparotomy was performed. We found gallbladder (GB) dilatation with fibrin surrounding the GB wall and a perforation in the border of the GB neck and cystic duct of around 10 mm in diameter. We performed cholecystectomy in the distal region of perforation. Antibiotics and analgesics were used. The patient was discharged on postoperative day 5. After 4 weeks, she was followed up and doing well with no complaints.

Conclusion

Early diagnosis and treatment are essential for GBP to prevent morbidity and mortality. Initial management is required; in patients with acute abdominal pain, the surgeon should suspect the cause may be GBP.

Highlights

• •Gallbladder perforation (GBP) is a rare but severe, often fatal, disease due to the delayed pathological process.
• •GBP can manifest in a variety of clinical presentations. Consequently, the diagnosis is frequently late or even missed.
• •Early diagnosis and treatment are essential for GBP to prevent morbidity and mortality.
• •The commonest treatment options for GBP are cholecystectomy, abscess drainage, and peritoneal lavage.
• •In our case of type I GBP, emergency exploratory laparotomy has been performed.

1. Introduction

Gallbladder perforation (GBP) is a rare but severe and often fatal disease due to its delayed pathological process, which demands urgent surgical intervention. GBP can result from acute cholecystitis, whether it is calculous or acalculous, in 6–12 % of cases [1].

GBP can manifest in a variety of clinical presentations [2]. Consequently, the diagnosis is frequently postponed or even missed [3]. Most cases are identified during surgery [2]. We report a case according to the Updating Consensus Surgical CAse REport (SCARE) 2020 guidelines [4].

2. Case report

A 68-year-old woman came to the emergency department with a complaint of abdominal pain in the last 1 week. The pain was felt in the epigastric region and migrated to the right upper quadrant, then extended to the whole abdomen. She had a history of frequent nausea, especially after meals, but reported no vomiting. She also complained of fever 1 week ago. Her last defecation was 1 day before entering the hospital, yellowish in color and liquid in consistency. There was no history of melena or hematochezia and no history of jaundice. She had a history of diabetes mellitus-controlled medication by glimepiride and untreated hypertension. The patient also had a history of cholelithiasis 1 year ago, but she had declined surgery.

A physical examination of the patient showed that she was alert, with vital signs including blood pressure of 100/70 mm Hg, heart rate of 112 beats/min, respiratory rate of 26 beats/min, and axillary temperature of 38.9 °C. On abdominal examination, bowel sounds were decreased, and there was muscular defense with tenderness throughout the abdominal region. On rectal touch examination, the anal sphincter was loose.

Laboratory tests found a decrease in hemoglobin (10.7 g/dL) and platelets (389 × 10³/mm³), leukocytosis (16.7 × 10³/mm³), blood glucose of 191 mg/dL, urea of 31 mg/dL, and creatinine of 1.23 mg/dL. The chest X-ray examination was within normal limits.

Abdominal ultrasound examination showed cholelithiasis and sludge, echo impression stones in the cystic duct, hepatomegaly, and little echo fluid in the lower right abdomen. The patient was diagnosed with generalized peritonitis and cholelithiasis with sepsis (qSOFA score 2; SOFA score 2). An emergency exploratory laparotomy was then performed. A midline abdominal incision was made. Intraperitoneally, we found 100 mL of pus in the right upper quadrant and gallbladder (GB) dilatation with fibrin surrounding the GB wall. A GBP in the border of the GB neck and cystic duct was around 10 mm in diameter (Fig. 1). We performed a cholecystectomy by ligating the distal region of the perforation. The patient received antibiotics, analgesics, and parenteral fluids.

Fig. 1.

Intraoperative imaging showing: (A) pus and fibrin (arrow) in the subserosa of the gallbladder (B) perforation (arrow) of around 10 mm in the gallbladder neck, (C) gallbladder with gallstones and sludge.

The patient was discharged after a full recovery on the fifth postoperative day. After 4 weeks, the patient was followed up and found to be doing well with no complaints.

3. Discussion

In an advanced stage of the disease, GBPs are a dangerous consequence of acute cholecystitis. Higher morbidity and mortality rates are associated, and they frequently affect an aged or comorbid demographic [5].

Cholecystitis, cholelithiasis, trauma, steroid use, vascular compromise, or tumors can all lead to GBP [6]. Around 9–12 % of instances of severe acute cholecystitis result in perforation, making it a common consequence [7]. The related death rate in one series was 24.1 %. In acute cholecystitis, progressive GB distention and inflammation are followed by vascular compromise, gangrene, necrosis, and, eventually, perforation [6]. Perforation can begin two days to several weeks after acute cholecystitis manifests [8]. An estimated 15–30 % of laparoscopic cholecystectomy patients experience iatrogenically caused perforation. It can also sporadically result from sharp or blunt trauma [9].

According to Niemeier [2]^, [3]^, [10]^, [11], three types of GBP exist: type 1 (acute) is GBP with generalized biliary peritonitis; type 2 (subacute) is associated with pericholecystic abscess and localized peritonitis; type 3 (chronic) has external or internal fistula formation, such as cholecystoenteric fistula. Considering the intraoperative findings, the most likely diagnosis our case was type I GBP (according to the updated Niemeir's classification) at the neck level with generalized biliary peritonitis.

Abdominal pain, fever, and vomiting are typical symptoms among patients with GBP. Diagnosing GBP promptly is challenging because these characteristics are frequently shared or mimicked by several abdominal conditions such as pancreatitis, cholangitis, and cholecystitis [12].

Diagnosing GBP as soon as possible is important. The recommended treatment strategy is an urgent cholecystectomy [13]. Imaging has a critical diagnostic role since clinical symptoms, particularly in diabetic patients, may be unclear and challenging to distinguish from uncomplicated cholecystitis. Symptoms and clinical indicators vary widely from mild non-specific abdominal discomfort to widespread acute peritonitis. GBP can occur with symptoms identical to uncomplicated acute cholecystitis. The GB wall is uneven or poorly defined on ultrasound (US), with localized or universal loss of its typical sonoreflectivity. There is a loculated pericholecystic collection or a lot of pericholecystic fluid. A more precise discovery, though not usually visible, is a focal defect in the GB wall [6].

Computed tomography (CT) helps diagnose suspected GBP when US results are unclear. CT is more effective than US for diagnosing GBP due to its greater capacity to show a focal wall defect [12]^, [14]. On CT, detecting a focal mural defect or an interruption of the GB wall may be easier. Stone spillage and pericholecystic or intrahepatic abscess are associated findings. A GBP occurs when intraperitoneal free fluid containing bile is present [6].

The most common treatment options for GBP are cholecystectomy, abscess drainage, and peritoneal lavage [15]. Emergency exploratory laparotomy with cholecystectomy, abscess removal, and peritoneal lavage has been performed in cases of type I GBP. The treatment for localized perforations (type 2) is up for discussion, and they are not always identified before surgery. As an initial step in treating GBP, antibiotic and NSAID therapy with further image-guided (US or CT) percutaneous drainage may be helpful, although this is not a certain course of action. Unless drainage is utilized as a palliative treatment in patients with significant comorbidities or severe systemic inflammatory disease, patients will need a second intervention. Regardless of the cause, cholecystectomy is the only effective treatment. In contrast, cholecystoenteric fistulae (type III GBP) will permit a thorough examination of the patient and surgical planning with a skilled surgeon, if the patient's condition permits it [16].

In this case, the patient was admitted with generalized peritonitis and sepsis, associated co-morbidities (diabetes mellitus and hypertension), and delayed presentation. In our hospital, no laparoscopic equipment was available in the emergency operating rooms. We decided to perform an emergency laparotomy (open cholecystectomy). However, if laparoscopic facilities exist and experienced operators in cases of GBP are available, a laparoscopic approach can be performed. Perforated, acute, or gangrenous cholecystitis can be treated by laparoscopic cholecystectomy, but if complications exist, such as unclear anatomy, a conversion procedure may be required [15].

Based on a systematic review of localized GBP cases (Neimeier type II), out of a total of 122 patients, laparoscopic surgery had a higher rate of complications and the need for further procedures, but it also required fewer hospital days than open cholecystectomy [16]. A laparoscopic cholecystectomy provides more successful drainage, sepsis control, and removal of the gangrenous gallbladder wall. Compared to open surgery, laparoscopy causes less tissue trauma and has better anesthetic techniques, and broad-spectrum antibiotics minimize the harmful effects of cytokine storms. Early laparoscopic surgery is likely not attempted due to concerns about bile duct injury, particularly in acute conditions [17]. In a retrospective study by Krishnamurthy et al. [17], of 15 GBP patients, 12 (80 %) had laparoscopic cholecystectomy using the retroinfundibular technique, with one conversion to open. One patient underwent reexamination for cystic artery bleeding, and two required endoscopic retrograde cholangiograms and bile duct stenting. No mortalities occurred. Early laparoscopic cholecystectomy is possible and safe in patients with acute GBP in hospital or centers with sufficient expertise.

4. Conclusion

An early diagnosis and treatment are essential for GBP to prevent morbidity and mortality. Thus, initial management is required. In patients with acute abdominal pain, the surgeon should suspect the cause may be GBP.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Patient consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Ethical approval

Ethical approval was waived by the authors institution.

Funding

None.

Guarantor

Warsinggih.

Research registration number

N/A.

CRediT authorship contribution statement

Warsinggih, Mudatsir, and Arham Arsyad: study concept and surgical therapy for this patient. Warsinggih, Mudatsir, Arham Arsyad, and Muhammad Faruk: Data collection and Writing-Original draft preparation. Warsinggih: senior author and the manuscript reviewer. Arham Arsyad and Muhammad Faruk: Editing and Writing. All authors read and approved the final manuscript.

Conflicts of interest

None.