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Spontaneous Type 1 Gallbladder Perforation in an Elderly Patient Presenting with Acute Generalised Peritonitis: a Case Report

  • Rajesh ChaudharyEmail author
  • Niraj Gupta
  • Ram Kishan Abrol
  • Saloni Sood
  • Mohamad Muzamil Ambekar
  • Suneet Katoch
Surgery
  • 28 Downloads
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  1. Topical Collection on Surgery

Introduction

Gallbladder (GB) perforation is a rare phenomenon, but a known complication of acute cholecystitis. It can be seen after acalculous cholecystitis too. The incidence of GB perforation in patients with cholecystitis has been reported to be from 2 to 11%, but Derici et al. reported it to be 4.8% in their study [1]. Spontaneous GB perforations are further rare and are mainly idiopathic. It is believed that the continuously rising pressure inside the GB leads to ischemia and inflammation leading to the GB perforation. This usually occurs at the fundus and presents with the features of a generalised peritonitis in the acute setting, but subacute and chronic perforations are also seen with pericholecystic fluid collections and cholecystoenteric and cholecystobiliary fistulae, respectively. It is seen in older age or immunocompromised people having comorbid medical ailments. Thus, it has gotten high morbidity and mortality, which is further compounded by delayed diagnosis and treatment. The mortality rate of GB perforation ranges between 0.8 and 11% [2]. Cholecystectomy with peritoneal toileting and drainage is the treatment of choice.

Case Report

A 77-year-old female was referred to our medical college from a secondary care institute with the history of acute pain abdomen for one day. The pain started in the upper abdomen five days before, moderate in intensity which suddenly increased and became generalised throughout the abdomen one day before. The pain was associated with nausea, vomiting, anorexia and failure to pass stools or flatus. There was no history of fever. The patient was not a known case of any chronic disease. The patient had good performance status. Her pulse rate was 92 per minute. Her blood pressure was 130/82 mm of mercury (mm/Hg). The patient had maximum tenderness in the right hypochondrium and right iliac fossa of the abdomen. There was no jaundice. Her total leucocyte counts (TLC) were 17,000 per cubic millimetre with 84% neutrophils. Her random blood sugar was 115 mg per decilitre (mg/dl), serum urea was 35 mg/dl, serum creatinine was 1.3 mg/dl, total serum bilirubin was 0.8 mg/dl, serum AST, ALT and alkaline phosphatise levels were 52.1, 36.5 and 106 units per litre (U/L), respectively. Her serum triglycerides, high-density lipoproteins, low-density lipoproteins, and very low-density lipoproteins were 101, 39, 54 and 20.2 mg/dl, respectively. Her serum amylase and lipase levels were 34 and 70.4 U/L, respectively. Possibility of acute generalised peritonitis secondary to perforated duodenal ulcer or ruptured appendix was kept and patient subjected to further investigations. Erect x-ray of the abdomen and chest did not show any free gas under the domes of the diaphragm. Ultrasonography of the abdomen was suggestive of a rent in the GB wall (sonographic hole sign) with free fluid in the abdomen (Fig. 1). The diagnosis was further confirmed on contrast-enhanced computed tomography (CECT) abdomen. The CT showed a rent of about 12 mm in the wall of distended GB with pericholecystic fluid and mesenteric fat stranding along with free fluid in the pelvis and both the paracolic gutters (Fig. 2). The patient was taken up for exploratory laparotomy after initial fluids and antibiotics. On opening the abdomen, there was about 500 ml of bilious fluid in the peritoneal cavity. There was a bile-stained, gangrenous area in the medial wall of the GB mainly in the fundus and body. The bile was trickling through it. There was saponification of the surrounding omental fat. Cholecystectomy was performed and thorough peritoneal toileting done. A drain was kept in the hepatorenal pouch. The drain was removed on the fourth post-operative day. The patient made an excellent recovery and was discharged home on the seventh post-operative day. She is still in follow-up and doing well.
Fig. 1

USG abdomen showing a rent in the GB wall

Fig. 2

CECT of the abdomen showing a rent in the GB wall along with pericholecystic fluid

Fig. 3

Intraoperative picture showing gangrenous, bile-stained GB wall and bilious-free fluid in the peritoneal cavity

Discussion

Gallbladder (GB) perforation is a rare phenomenon seen in patients with cholecystitis. It is usually seen in the old, immunocompromised people or in people having diabetes mellitus, atherosclerosis, malignancies or organ failures. Although acute cholecystitis is seen more frequently in females, GB perforations are seen more commonly in males. The incidence of GB perforation after acute cholecystitis ranges between 0.8 and 11% [1]. It is not so common to see GB perforations in people with acalculous cholecystitis [2]. The site of perforation is the fundus of the GB in about 60% of the cases [1]. This is the most distal part of the GB and thus, it has gotten a compromised blood supply. The GB distension leads to decreased venous and lymphatic return which ultimately leads to ischemia and necrosis of the GB wall. Neimeier classified the GB perforation into three types in 1934 [3]. Type 1 perforations are acute perforations presenting with the features of acute generalised peritonitis. Type 2 perforations are subacute in nature and present with pericholecystic fluid collections or abscesses. Type 3 perforations are chronic and present with cholecystoenteric fistulae. Further, type 4 has been introduced by Andersen et al. in 1987, associated with cholecystobiliary fistula [4]. The GB perforations are further classified as spontaneous, traumatic and iatrogenic in nature. The spontaneous group has been further subdivided into idiopathic and secondary due to causes like infection, gallstones or congenital causes [5]. Spontaneous GB perforation is further rare. This condition presents with features similar to those of acute cholecystitis, and since most of the times these patients are old and immunocompromised, the clinical signs and symptoms are further suppressed; thus, the diagnosis is delayed and is associated with high morbidity and mortality. Ultrasonogram of the abdomen is the initial preferred investigation. Although GB wall thickening, oedematous GB wall, pericholecystic fluid and abscesses may be seen in GB perforation, the demonstration of sonographic hole sign is most consistent with GB wall perforation [6]. Other direct evidence of GB perforation is the presence of free gallstones outside the gallbladder. The sentinel clot sign within and around the GB on CECT of the abdomen should raise the suspicion of GB perforation [7]. CECT of the abdomen will show GB wall discontinuity along with haemobilia. There may be pericholecystic fluid collection, abscess or biloma formation with free extraluminal gallstones in it. Apart from this GB oedema, intramural gas, GB wall thickness, wall enhancement, intramural haemorrhage, GB stones, bile duct stones and cystic duct stones can be demonstrated by CECT. The CT of the abdomen has gotten 88% sensitivity for the detection of GB perforations; thus, it is the investigation of choice for pre-operative diagnosis of GB perforation [4, 8]. Type 1 perforations are usually present with acute generalised peritonitis in patients of less than 50 years of age. Thus, they will require urgent laparotomy where cholecystectomy is done along with peritoneal toileting and drainage. In type 2 patients, the fluid collections or abscesses are drained usually under radiological guidance, sepsis is controlled and once the patient is stabilised cholecystectomy is done. They are also usually less than 50 years of age. Type 3 and type 4 patients are difficult to treat, as they are usually older than 80 years of age and have long-standing gallstone disease and other comorbid conditions like diabetes mellitus and atherosclerotic heart disease. Type 3 GB perforations require repair of the cholecystoenteric fistula along with cholecystectomy. Type 4 fistulae require cholecystectomy and choldocholithotomy. The duct can be repaired primarily over T Tube or sometimes duct enterotomy may be required. Our patient was a 77-year-old female who did not have any gallstones, had no known comorbid conditions, and had type 1 GB perforation. She was most likely suffering from acalculous cholecystitis. The mortality was as high as 42% [9] around 60 years ago but has now come down to 12–16% [1, 10] these days, thanks to newer radiological advances, quick sepsis control, better anaesthesia techniques, and improved intensive care management [1, 4].

Conclusion

Spontaneous perforations of the GB in females of more than 50 years of age are a rare phenomenon. These patients are very frail. The typical features of generalised peritonitis are usually not seen. Further, the diagnosis is confused with acute cholecystitis. The diagnosis of GB perforation is not always possible pre-operatively. Thus, a high index of suspicion for the condition and a good clinical knowledge supported by radiological investigation can help to avoid delay in the diagnosis and treatment of a patient having biliary peritonitis with GB perforation.

Notes

Author’s Contributions

RC contributed substantially to the conception, design, acquisition of data, analysis and interpretation of data, drafting the article, critical revision of the article and final approval of the version to be published. NG contributed substantially to the conception and design, acquisition of data, critical revision of the article and final approval of the version to be published. RKA contributed substantially to the conception and design of the article and final approval of the version to be published. MMA contributed substantially to the conception and design, acquisition of data, critical revision of the article and final approval of the version to be published. SS contributed to the acquisition of data, critical revision of the article and final approval of the version to be published. SK contributed substantially to the conception and design, acquisition of data, critical revision of the article and final approval of the version to be published.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.

Ethical Approval

This was a case report and the patient identity was totally concealed; hence, the ethical approval was not taken.

Consent

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

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Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of SurgeryDr. R.P. Government Medical College KangraTandaIndia
  2. 2.Department of AnaesthesiaDr. R.P. Government Medical College KangraTandaIndia

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