Ultrasound of the Month: Gallbladder Perforation
/THE CASE
A male in his 60s presented to the emergency department for right upper quadrant abdominal pain. His past medical history included coronary artery disease, type II diabetes, atrial fibrillation, alcohol use disorder, cirrhosis complicated by portal venous hypertension, chronic kidney disease, prior Escherichia coli (E. coli) empyema due to complicated pneumonia, and a prior perisplenic abscess requiring percutaneous drainage. He described one day of severe persistent right upper quadrant pain radiating to his back associated with nausea. There were no known aggravating or alleviating factors. He denied fevers, emesis, dysuria, hematuria and change in bowel function. However, one week prior to presentation he had a brief episode of right upper quadrant pain and nausea after eating that resolved spontaneously.
On evaluation, he was afebrile and hemodynamically stable. He did not have abdominal tenderness on exam, specifically at Murphy’s or McBurney’s point. The remainder of his exam was unremarkable. His lab work was notable only for a mildly elevated alkaline phosphatase. A bedside right upper quadrant ultrasound was performed, and the images are below.
Image 1. Gallbladder visualized in long axis.
Image 2. Gallbladder visualized in short axis
In summary, it demonstrated cholelithiasis, gallbladder wall thickening, and pericholecystic fluid. The gallbladder fundus was noted to have an abnormal shape with surrounding echogenic enhancement. These findings were concerning for cholecystitis complicated by gall bladder perforation and abscess formation. Confirmatory testing with CT of the abdomen and pelvis with intravenous (IV) contrast confirmed acute cholecystitis with perforation, with a fluid filled rim-enhancing tract extending from the gallbladder fundal wall defect to the anterior surface of the liver (Image 3).
Image 3. CT Abdomen and pelvis with IV contrast showing perforated cholecystitis
Blood cultures were obtained and a dose of piperacillin / tazobactam (Zosyn) was administered. General surgery was consulted, and given the patient's significant comorbidities, he was transferred to a tertiary care academic center for further evaluation and management. The following day, Interventional Radiology placed a percutaneous cholecystostomy tube. Fluid cultures obtained during the procedure grew E. coli and rare budding yeasts. He was transitioned to cefdinir and fluconazole for a full 7-day course of antibiotics and discharged from the hospital on day three, with instructions to follow up with general surgery for an outpatient cholecystectomy.
ACUTE PERFORATED CHOLECYSTITIS PATHOPHYSIOLOGY
Gallbladder perforation is most often a rare complication of acute cholecystitis, which carries a high rate of morbidity and mortality. Risk factors associated with increased risk of acute perforated cholecystitis include age greater than 65 years old, as well as diabetes mellitus, atherosclerosis, or organ failure (1, 2). Gallstones are noted in approximately 86% of cases of perforation (3). It is estimated that 3-15% of patients with acute cholecystitis with gallstones result in perforation (4). One theory proposes that calculous obstruction of the cystic duct leads to distention of the gallbladder which leads to eventual vascular compromise, necrosis, and perforation of the wall (5). It is often a sequela of advanced gallbladder inflammation such as emphysematous cholecystitis and less commonly malignancy (1, 2). Gallbladder perforation is also a known complication of laparoscopic cholecystectomies and can rarely be a sequela of trauma. The most well-accepted classification of acute perforated cholecystitis is the Niemeier classification which is outlined as below (3,6).
Type I: acute perforation into the peritoneal cavity associated with generalized peritonitis
Type II: subacute perforation with fluid localization at site of perforation, pericholecystic abscess and localized peritonitis
Type III: chronic perforation with fistula formation between the gallbladder and another viscus
The gallbladder fundus is the most common site of perforation, as was the case in our patent. It is typically associated with elevated inflammatory markers such as white blood cell count or c-reactive protein (CRP). Complications of acute gallbladder perforation include localized peritonitis, hepatic, subhepatic, or pelvic abscess formation, pneumonia, pancreatitis, acute renal failure, and sepsis (7).
Clinicians should keep a high threshold of suspicion for perforated cholecystitis, as there are no classical signs or symptoms that indicate the disease process. Whereas most patients may appear toxic or have days of progressively worsening pain due to peritonitis, others may have prompt resolution of their pain due to local containment of a pericholecystic abscess.
Patients should be resuscitated as deemed appropriate. In those with concern for sepsis, blood cultures, broad spectrum IV antibiotics and fluids should be given as needed. Definitive care is procedural or surgical intervention. Many patients will require cholecystectomy, but some patients – particularly those with significant comorbid conditions such as in our case – may first be treated with percutaneous cholecystostomy tubes and subsequent cholecystectomy once the patient is more stable and the acute inflammatory process has improved (5).
IMAGING IN THE EVALUATION OF ACUTE PERFORATED CHOLECYSTITIS
The high morbidity and mortality rate associated with acute perforated cholecystitis may be due to delay in diagnosis. Ultrasonography in conjunction with CT imaging can assist in making a quick diagnosis. Sonographic signs of cholecystitis include pericholecystic fluid collection, and a thickened gallbladder wall often in the presence of stones. Signs of perforation vary widely. Direct visualization of the gallbladder wall defect, as present in our case, is the most specific sign. The presence of gallstones outside of the gallbladder wall, striated appearance of the gallbladder wall, and adjacent fluid collections, abscesses or fistulas are other findings that could be seen on ultrasound (5, 8). Sonographic visualization of the aforementioned signs of perforation should prompt CT imaging and/or surgical consultation.
Ultrasound is the gold standard for diagnosing cholelithiasis because it is more sensitive for detecting gallstones. CT is more sensitive for diagnosing cholecystitis (92% versus 79%, p = 0.015) and its complications, including perforation, because of its improved detection of inflammatory processes and demonstrating the exact anatomic location of perforations, abscesses, and fistulas (9). However, employing ultrasound first may make a timelier diagnosis and decrease the time to surgical consultation, the risks of radiation, and healthcare spending. Ultrasound and CT should therefore be employed as complementary imaging modalities in the evaluation of acute perforated cholecystitis.
AUTHORED BY SIERRA HADJU, MD
Dr. Hadju (@sierrahadju) is a PGY-2 in Emergency Medicine at the University of Cincinnati.
PEER REVIEW By Jessica Baez, MD
Dr. Baez is an Ultrasound Fellowship Trained and an Assistant Professor in Emergency Medicine at the University of Cincinnati.
EDITING AND LAYOUT BY MARTINA DIAZ, MD
Dr. Diaz (@martina_diazb) is a PGY-4 in Emergency Medicine at the University of Cincinnati and the current Resident Editor of Ultrasound of the Month.
REFERENCES
Jansen, S, Stodolski, M, Zirngibl, H et al. Advanced gallbladder inflammation is a risk factor for gallbladder perforation in patients with acute cholecystitis. World J Emerg Surg 13, 9 (2018). https://doi.org/10.1186/s13017-018-0169-2
Suleiman J, Mremi A, Tarmohamed M, Sadiq A, Lodhia J, Concealed gallbladder perforation: a rare case report, Journal of Surgical Case Reports, Volume 2021, Issue 6, June 2021, rjab245, https://doi.org/10.1093/jscr/rjab245
Date RS, Thrumurthy SG, Whiteside S, Umer MA, Pursnani KG, Ward JB, Mughal MM. Gallbladder perforation: case series and systematic review. Int J Surg. 2012;10(2):63-8.
Bhatwal AS, Deolekar SR, Karandikar SS. An unusual presentation of gall bladder perforation with hepatic subcapsular collection. Indian J Surg. 2013;75(S1):261-5
Weerakkody Y, Di Muzio B, El-Feky M, et al. Gallbladder perforation. Reference article, Radiopaedia.org (Accessed on 11 Jun 2023) https://doi.org/10.53347/rID-17011
Niemeier OW. Acute Free Perforation of the Gallbladder. Ann Surg. 1934 Jun;99(6):922-4. doi: 10.1097/00000658-193499060-00005. PMID: 17867204; PMCID: PMC1390061.
Derici H, Kara C, Bozdag AD, Nazli O, Tansug T, Akca E. Diagnosis and treatment of gallbladder perforation. World J Gastroenterol. 2006 Dec 28;12(48):7832-6. doi: 10.3748/wjg.v12.i48.7832. PMID: 17203529; PMCID: PMC4087551.
Gayler T. Sonographic Findings of Gallbladder Perforation With Hepatic Abscesses. Journal of Diagnostic Medical Sonography. 2018;34(2):132-136. doi:10.1177/8756479317736066
Fagenholz PJ, Fuentes E, Kaafarani H, Cropano C, King D, de Moya M, Butler K, Velmahos G, Chang Y, Yeh DD. Computed Tomography Is More Sensitive than Ultrasound for the Diagnosis of Acute Cholecystitis. Surg Infect (Larchmt). 2015 Oct;16(5):509-12. doi: 10.1089/sur.2015.102. Epub 2015 Sep 16. PMID: 26375322.
