Diagnosis
Acute cholecystitis with perforated gallbladder
Findings
There are inflammatory changes about the gallbladder with a defect seen through the gallbladder wall at its fundus. There is extensive pericholecystic and perihepatic complex fluid, likely representing bile. There is a gallstone noted in the cystic duct as well as multiple gallstones in the gallbladder.
Discussion
Although uncommon, occurring in approximately 2% to 15% of patients with acute cholecystitis, radiologic diagnosis of a perforated gallbladder is important in patients with acute cholecystitis because of the high mortality (70%) associated with this condition.1 Gallbladder perforation is the most severe complication of acute cholecystitis, and the clinical presentation can range from that of nonspecific abdominal symptoms to an acute abdomen with peritoneal signs. Because it is often difficult to distinguish acute cholecystitis from perforation clinically, imaging is warranted. Bile leak from a ruptured gallbladder may not produce immediate symptoms of peritonitis if it is contained within the extraperitoneal gallbladder fossa. Therefore, further evaluation with ultrasound or computed tomography (CT) will provide more information. Following perforation, CT and ultrasonography both show complex fluid collections surrounding the gallbladder. CT images may demonstrate ancillary findings such as pneumobilia. The crumpled wall of a decompressed gallbladder floating within fluid of the gallbladder fossa is also indicative of perforation. Other times a focal disruption in the gallbladder wall can be seen as in our case. According to Stephadinis, et al.,2 sensitivity of CT in the detection of gallbladder perforation and biliary calculi was found to be 88% and 89%, respectively. We recommend that it be performed in all such cases. A classification system of 3 types of gallbladder perforation has been described in earlier decades by Niemeier and include: acute or Type 1 (33% to 37%), manifesting with generalized peritonitis; subacute or Type 2 (43% to 53%), in which there is localization of fluid at the site of perforation with the formation of a pericholecystic abscess; and chronic or Type 3 (10% to 19%), in which internal (bilio-biliary or bilio-enteric) or external fistulae occur.
Once confirmed, treatment of gallbladder perforation requires immediate surgery with performance of a cholecystectomy.
- Morris BS, Balpande PR, Morani AC, et al. CT appearances of gallbladder perforation. Br J Radiol. 2007;80:898-901.
- Stephanidis D, Sirinek KR, Bingener J. Gallbladder perforation: Risk factors and outcome. J Surg Res. 2006;131:204–208.