ª Springer Science+Business Media New York 2014
Abdominal Imaging
Abdom Imaging (2014) DOI: 10.1007/s00261-014-0121-1
Cross-sectional imaging of perforated gallbladder Adeel R. Seyal, Keyur Parekh, Fernanda D. Gonzalez-Guindalini, Paul Nikolaidis, Frank H. Miller, Vahid Yaghmai Department of Radiology, Northwestern Memorial Hospital, Northwestern University-Feinberg School of Medicine, 676 North Saint Clair Street Suite 800, Chicago, IL 60611, USA
Abstract Gallbladder perforation is a potentially life-threatening condition commonly seen as a complication of acute cholecystitis. Urgent surgical intervention is often needed to reduce serious morbidity and mortality. It presents a diagnostic challenge due to nonspecific symptoms, leading to a delay in diagnosis. Imaging plays a vital role in early identification of this potentially fatal condition and evaluation by more than one imaging modality may be required to make the diagnosis. Knowledge of specific and ancillary imaging findings is crucial to avoid misdiagnosis. In this article, we will review the risk factors, pathophysiology, and surgical classification of gallbladder perforation and discuss the role of multimodality imaging in its diagnosis. Differential diagnoses on imaging will also be discussed. Key words: Gallbladder perforation—Computed tomography—Ultrasound—Magnetic resonance imaging—Biliary fistula—Gallstones
Gallbladder (GB) perforation is an uncommon and potentially life-threatening condition, most commonly seen as a complication of acute cholecystitis. With improvements in antibiotic therapies and increasing number of early cholecystectomies, the incidence has dropped in acute cholecystitis from 2% to 15% as cited in the literature from past 50 years [1–3] to 0.8–3.2% in more recent reports [1, 3]. GB perforation may develop as early as 2 days after the onset of acute cholecystitis or up to several weeks later [4, 5]. GB perforation often requires urgent surgical intervention but is rarely diagnosed preoperatively. Clinical differentiation from
Correspondence to: Vahid Yaghmai; email: v-yaghmai@northwestern. edu
uncomplicated acute cholecystitis is often difficult leading to a delay in diagnosis, higher incidence of complications, and poorer outcomes [1, 6, 7]. GB perforation can also be seen as a result of traumatic injury and often follows an insidious clinical course making the diagnosis difficult. It can be easily missed on imaging; thus, delaying management which can lead to substantial morbidity and mortality [8]. Weckner et al. [9] reported 107 patients at autopsy who had died secondary to GB perforation without the diagnosis being suspected. Recent advances in medical imaging have enabled early detection of GB perforation allowing timely institution of appropriate management. The purpose of this article is to provide a comprehensive review of multimodality imaging findings of this potentially fatal abdominal emergency.
Predisposing conditions There is an increased tendency for acute acalculous cholecystitis to progress to perforation, although most cases of GB perforation are associated with calculous cholecystitis because of its higher incidence [10]. GB perforation is typically seen in the setting of diseased GB such as cholecystitis, malignancy and corticosteroid use, and vascular compromise [6]. Diabetes mellitus and atherosclerotic heart disease are also thought to be contributory [4]. Trans-catheter arterial chemoembolization (TACE) can lead to acute ischemic cholecystitis, as a result of non-target embolization of cystic artery [11, 12]. This can progress to GB necrosis and perforation. Similarly, trans-catheter arterial radioembolization (TARE) can cause radiation-induced cholecystitis with rare progression to perforation [13]. Despite the fact that more females are diagnosed with acute uncomplicated cholecystitis [14], perforation is more commonly seen in males [1, 15–17] with elderly
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
patients being particularly susceptible to perforation [7, 18]. An otherwise normal GB can perforate secondary to trauma (iatrogenic, blunt, or penetrating). GB injury is found in 2% of patients with blunt abdominal trauma undergoing laparotomy in association with other visceral injuries (rarely isolated GB injuries occur). Perforation (full-thickness) is the most common form of GB injury in blunt abdominal trauma with the treatment of choice being cholecystectomy [8, 19]. Usually, the GB is protected because of its anatomic location behind the liver and ribs. Certain conditions increase the risk of its perforation in the setting of trauma such as thin-walled normal GB, distended GB in the pre-prandial state, malpositioned GB secondary to cirrhosis, and alcohol consumption which increases sphincter of Oddi tone causing GB distension, thus, making it more prone to injury [20]. Various predisposing factors for GB perforation are listed in Table 1.
Neimeier’s classification of perforated GB In 1934, Neimeier [21] proposed a classification for GB perforation that is still used today and has prognostic implications: Type I, acute free perforation of the GB into the peritoneal cavity without protective adhesions (Fig. 1A); Type II, subacute perforation surrounded by a pericholecystic abscess walled off by adhesions (Fig. 1B); and Type III, chronic perforation with presence of a fistulous communication between GB and a viscus (Fig. 1C). Subacute (type II) perforations are the most common type in most reported series [22, 23] accounting for 60% of all cases; chronic (type III) perforation seen in 30% and acute perforation (type I) in 10%. Type I perforations usually carry a higher mortality. Fletcher et al. reported 40% mortality for type I, 4% mortality for type II. and no mortality for type III perforations [22]. For type III perforations, one-third present with gallstone ileus [6]. Table 1. Predisposing conditions for GB perforation Diseased GB Cholecystitis (acute calculous or acalculous or chronic) Cholelithiasis Systemic diseases (Diabetes mellitus and atherosclerotic heart disease) Drugs (e.g., corticosteroids) Vascular compromise (ischemic injury) Normal GB Trauma (blunt and penetrating) Iatrogenic
Fig. 1. Neimeier’s classification of perforated GB. A Type I: acute free perforation. B Type II: subacute perforation with peri-cholecystic abscess. Gallstone may be seen outside of GB within the abscess. C Type III: chronic perforation with formation of cholecystoenteric fistula.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Pathophysiology One proposed mechanism of GB perforation is impaction of a gallstone in the cystic duct that leads to obstruction and accumulation of bile within the GB causing distension. The presence of intraluminal bile salts causes chemical inflammatory reaction of the GB mucosa. Progressively worsening distension will compromise the vascular supply leading to gangrene, necrosis and perforation of the GB wall [6, 24]. It is believed that Rokitansky–Aschoff sinuses can become dilated by forceful contractions of the GB forming diverticula. Infection of these dilated sinuses may eventually lead to necrosis and perforation of the GB wall [24, 25]. Glenn and Moore [25] proposed this as the likely mechanism for intrahepatic rupture of the GB leading to formation of hepatic abscesses. Focal ischemia of unknown etiology has also been proposed as a mechanism of GB rupture, especially in cases without acute inflammation or gallstones [26]. Perforation can be found in the fundus, body, and the neck of GB although fundus is the most commonly perforated site secondary to its relatively poor blood supply (farthest from the cystic artery thus most prone to ischemic injury) [10, 27].
Clinical manifestations GB perforation often presents a diagnostic challenge. Clinical signs and symptoms depend on the etiology and are usually nonspecific. They can range from right upper quadrant to generalized abdominal pain, tenderness, rigidity ,and guarding (signs of peritonitis) to nonspecific abdominal symptoms (nausea, vomiting, vague upper abdominal discomfort, or pain). Often it is difficult to differentiate GB perforation from uncomplicated acute cholecystitis likely because bile leak from the perforation might be contained [10, 28]. GB perforation in acute cholecystitis should be suspected in patients who become toxic or have sudden clinical deterioration for unexplained reasons [29]. Complications include bile leak and peritonitis;
Table 2. Radiologic features of GB perforation Specific imaging findings Focal defect in GB wall Extraluminal gallstone Ancillary imaging findings Pericholecystic fluid collection/abscesses Thickened irregular GB wall or focal bulge Distended GB Omental or mesenteric fat streaking Pneumobilia
abscesses around the GB fossa, intraperitoneal or intrahepatic; intraperitoneal air; sepsis or septic shock; fistulae; and bowel obstruction [30]. Mortality worsens with a delay in diagnosis. A mortality rate as high as 42% has been reported [25]. However, advances in perioperative management (anesthesiology and intensive care conditions) have reduced the mortality rates to 7–16% [1, 7, 31].
Imaging findings Various imaging features of GB perforation are listed in Table 2. Ultrasound (US) is usually the initial method of investigation of choice in patients with suspected acute cholecystitis or its complications though findings may be non-specific. Chau et al. first described the ‘‘sonographic-hole’’ sign, which is the direct visualization of a GB wall defect on US (Fig. 2). It is a very specific sign of GB perforation that can be seen on US, computed tomography (CT), or magnetic resonance (MR) imaging but is not always visualized [32, 33] (Figs. 3, 4, 5). Kim et al. compared findings on US with CT in 13 patients with surgically confirmed GB perforation and found a wall defect in seven patients on CT and none on US. They concluded that CT is superior to US for the diagnosis of GB perforation because of its ability to better demonstrate a focal wall defect [23]. Finding gallstones outside of the GB is also specific for GB perforation in the correct clinical setting. Interruption of the GB wall and extraluminal radio-opaque gallstones is usually better appreciated on CT [6, 33] (Fig. 6). Gas within gallstones (‘‘Mercedes Benz’’ sign) outside of the GB may be present and can facilitate the diagnosis of GB perforation on CT or MR imaging [6] (Fig. 7). A focal bulge in the GB wall has been described as a sign of GB rupture [6, 23]. Mesenteric or omental fat streaking is another ancillary finding of GB perforation seen on CT. Subacute GB perforations (Type II) are usually contained by a pericholecystic abscesses. They appear as complex echogenic pericholecystic fluid collections on US usually in the presence of a thickened hypoechoic edematous GB wall and cholelithiasis. CT further helps to identify and evaluate the location and extent of such abscesses (Fig. 8). On contrast-enhanced T1-weighted MR images, pericholecystic or intrahepatic abscesses appear as fluid collections with rim enhancement (Fig. 9) [34]. Low signal on apparent diffusion coefficient (ADC) map images reflecting restricted diffusion can help in characterization of pericholecystic fluid as an abscess (Fig. 10). In chronic (Type III) perforations, there is formation of cholecystoenteric fistula secondary to chronic inflammation of the GB and its proximity to the intestine. Once
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 2. 69-year-old female with perforated acute gangrenous cholecystitis (Type I perforation). A, B Longitudinal and C transverse GB US images show focal wall defect (arrow) and
sloughed membranes (arrowheads). D Sagittal reformatted CT image shows a visible wall defect (arrow). Gangrenous change is seen in up to 30% of patients with acute cholecystitis.
a fistulous communication is established, air can pass from the intestine to the GB and biliary tree causing pneumobilia (Fig. 11). Also, gallstones can pass through to the bowel frequently causing obstruction (gallstone ileus), most often in the ileum followed by jejunum. Most obstructing gallstones are at least 2.5 cm in diameter. The terminal ileum is the narrowest part of the small intestine and therefore the most likely site of obstruction. Rarely, gallstones can obstruct other parts of the gut such as duodenum or pylorus causing gastric outlet obstruction (Bouveret’s syndrome). The classic radiologic sign for gallstone ileus is the ‘‘Rigler’s triad’’ (pneumobilia, mechanical bowel obstruction, and an ectopic gallstone), which can be seen in 14.8% of cases on abdominal radiographs but up to 77.8% cases on CT [35]
(Fig. 12). CT can accurately show the fistula and the degree and level of bowel obstruction [36]. MR imaging can be also useful in identifying the fistulous communication (Fig. 13). For traumatic GB rupture (blunt, penetrating, or iatrogenic), CT is most effective for diagnosis as it is usually done initially in a trauma setting (Fig. 14). Imaging findings on CT and MR include a collapsed GB despite prolonged fast (which would distend the GB); disruption of the GB wall; intraluminal hemorrhage (hemobilia); complex pericholecystic fluid collections; omental or mesenteric fat streaking; and thickened and edematous GB wall [19, 20]. US findings in traumatic GB rupture may include a collapsed GB despite prolonged fast, disruption of the GB wall with focal loss of
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 3. Acute free perforation of the GB (Type I) in a 51-yearold male with acute cholecystitis. A Initial presentation axial CT post contrast with B coronal reformat show distended GB with surrounding liver hyperemia suggestive of cholecystitis
(arrows). C Axial and D coronal images of CT performed after 4 days because clinical deterioration shows GB wall defect (arrows) with extensive pericholecystic inflammatory changes (asterisk) consistent with acute perforation.
its reflectivity, highly echogenic intraluminal contents, complex echogenic pericholecystic fluid and a thickened, hypoechoic GB wall [20]. Though all of these findings may not be present, their identification helps in making the diagnosis in suspected cases. Spilled gallstones can be seen as a complication of cholecystectomy as a result of iatrogenic GB perforation. They are most commonly seen around the liver, GB fossa, Morrison’s pouch, pelvis, and port sites. They are encountered in approximately 7% (but as many as 30%) of laparoscopic cholecystectomies secondary to GB perforation during surgical dissection and extraction [37]. US shows mobile hyperechoic foci with posterior acoustic shadowing (Fig. 15A). With superimposed infection, abscesses may form around gallstones, which
appear as hyperechoic foci (gallstones) within hypoechoic fluid collections. On CT, stones with higher calcium content appear as high attenuation foci, whereas pure cholesterol stones and those with low calcium content may go undetected (Fig. 15B). On MR, pigmented gallstones appear hyperintense on T1-weighted images whereas others are typically hypointense on both T1- and T2-weighted images (Fig. 15C). CT and MR imaging (Fig. 16) can show inflammatory reaction or fluid collections around the spilled gallstones. Less frequently, spilled gallstones can erode and migrate through the abdominal wall, diaphragm, and gastrointestinal tract forming fistula (Fig. 16C). All efforts should be made to retrieve spilled gallstones during laparoscopic cholecystectomy, whereas infected retained gallstones should be
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
57-year-old male with large intrahepatic abscess secondary to subacute (Type II) perforation of the GB. A US (longitudinal view) of the GB (asterisk) and right hepatic lobe shows a large intrahepatic fluid collection (arrow) containing multiple hyperechoic foci (arrowhead) with posterior acoustic shadowing consistent with gallstones. B Axial noncontrast CT shows pericholecystic fluid collection (arrow) and mesenteric fat stranding (asterisk). C Axial T1-weighted post-contrast MR images show GB wall defect (arrow), extraluminal hypointense gallstones (arrowhead) within an adjacent intrahepatic abscess. D Axial T1-weighted post contrast and E T2weighted MR image shows large intrahepatic fluid collection (arrow) with restricted diffusion on ADC map F consistent with multiloculated intrahepatic abscess formation.
b Fig. 4.
CT-guided GB drainage) can be employed with elective cholecystectomy depending on the condition of the patient [31, 39]. Chronic perforations are usually diagnosed in symptomatic patients. For gallstone ileus (type III perforation), enterolithotomy with stone extraction is generally performed due to its low incidence of complications. Cholecystectomy may be performed at the time of initial surgery or at a later date. Also, fistula repair can be undertaken at the time of surgery depending on the condition of the patient though spontaneous closure of fistula can be seen in greater than 50% of the cases [40, 41].
Mimics of perforated GB surgically removed to prevent recurrent infections [37, 38].
Management highlights Cholecystectomy, drainage of abscess if present, antibiotics, and peritoneal lavage are considered the mainstays of treatment of GB perforation [16]. For acute (type I) perforations, urgent open or laparoscopic cholecystectomy or cholecystostomy is done. Management of subacute (type II) perforations is relatively more complex with lack of consensus in the published literature. If the patient is fit for surgery, cholecystectomy (open or laparoscopic) is recommended. For patients who are critically ill or otherwise unfit for surgery, less invasive options (percutaneous US- or
Fig. 5. 69-year-old male with perforated GB (Type II perforation) after recent TARE (Yttrium-90) of the right liver lobe for metastatic pancreatic cancer with neuroendocrine differentiation. Axial contrast-enhanced CT image shows distinct GB wall defects (arrows) with surrounding pericholecystic fluid.
A high index of clinical suspicion and knowledge of multimodality imaging features is necessary to diagnose GB perforation and differentiate it from other conditions with overlapping imaging findings. In addition, relevant clinical history is essential for accurate diagnosis. Pneumobilia and air within the GB is suspicious for perforation but can be seen with recent biliary instrumentation. Presence of gas-containing gallstones inside the GB can mimic cholecystoenteric fistula but may lack any other signs of GB perforation (Table 2). Intramural air (emphysematous cholecystitis), sloughing of GB mucosa (gangrenous cholecystitis), and infiltrating GB cancer without obvious wall defects should be carefully evaluated to avoid misdiagnosis of GB perforation (Fig. 17). It can be challenging to differentiate GB perforation with pericholecystic abscess from GB carcinoma or xanthogranulomatous cholecystitis. GB cancer can appear on cross-sectional imaging as an intraluminal polypoid mass, wall thickening (focal or diffuse), or a mass replacing the GB [42]. It is usually T1 hypointense and T2 hyperintense when compared with the surrounding liver. On postcontrast MR, GB cancer shows early irregular enhancement that persists into delayed images [43]; whereas, pericholecystic abscess typically shows postcontrast rim enhancement. Coexistence of diffusely thickened GB wall, continuous mucosal line with surface enhancement, hypodense intramural nodules, and cholelithiasis on crosssectional imaging is suggestive of xanthogranulomatous cholecystitis. Detecting fat within the intramural nodules on chemical-shift MR imaging further aids in the diagnosis of xanthogranulomatous cholecystitis [44]. Extensive inflammatory changes in the GB fossa secondary to duodenal ulcer perforation can obscure the anatomy of the region necessitating careful GB evaluation. Also, it can be challenging to confidently diagnose GB perforation in abdominal trauma patients with liver laceration and fluid in the region of the GB fossa.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder b Fig. 6.
Extraluminal gallstones and liver abscess in an 87year-old male with subacute (Type II) perforation of the GB. A–C Axial noncontrast CT images show multiple gallstones within the GB (arrow, A), pericholecystic/intrahepatic abscess (arrowhead), and irregular contour of GB fundus (arrow, B). Extraluminal gallstones (arrow, C) are noted. D Coronal reformatted image shows free fluid (asterisk) and extraluminal gallstones (arrows). E Sagittal reformatted image shows extraluminal gallstone (arrow), intrahepatic abscess (arrowhead), and extensive mesenteric fat stranding (asterisk).
Fig. 7. 56-year-old male with a duodenal gallstone secondary to a cholecystoduodenal fistula (Type III perforation). A Axial contrast-enhanced CT image shows a 1.6 cm gallstone (arrow) within the GB. B Coronal CT image from a repeat scan after 3-months shows the same gallstone now in proximal duodenum (arrow) with pneumobilia (arrowhead) and stranding in the GB fossa. C Axial and D coronal T2-
weighted MR images show a hypointense duodenal gallstone (arrow) with a normal caliber common bile duct (arrowhead, C) and without imaging evidence of small bowel obstruction. Note the Mercedes-Benz sign (air within the gallstone) (arrowhead, D). Presence of gas within the extraluminal gallstones helps diagnose gallstone within duodenum and GB perforation.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 8. 70-year-old male with large pericholecystic fluid collections and extraluminal gallstones secondary to a perforated GB (Type II perforation). A, B US images (longitudinal views) show large pericholecystic fluid collections (arrow). Note the presence of an extraluminal gallstone (arrowhead, A). A large gallstone is seen inside the GB (asterisk, B). C Axial and D sagittal post-contrast CT images show pericholecystic fluid collections (arrows), edematous GB wall with surrounding liver hyperemia (arrowhead, D). A focal wall
defect in the GB wall is clearly seen in the axial image, communicating with a pericholecystic fluid collection (arrowhead, C). E, F Axial T2-weighted MR images show large intraluminal gallstones (arrows) and multiple hypointense gallstones adjacent to a focal wall defect (arrowhead, F). G Photograph of the GB specimen after cholecystectomy shows an area of perforation (arrow) with a protruding gallstone. Note the two large gallstones and their corresponding appearance on MR images (E, F).
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 8.
continued
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 9. 58-year-old-female with pericholecystic multiloculated abscess secondary to perforated GB (Type II perforation). A Axial and B coronal T1-weighted post-contrast MR images with fat saturation show multiloculated pericholecystic fluid
with enhancing walls (arrows) consistent with multiloculated abscess. C Axial and D coronal T2-weighted MR images show hyperintense loculated pericholecystic fluid collection (arrows). A gallstone is seen in the GB (arrowhead, C).
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 10. Perforated GB with pericholecystic abscesses (Type II perforation) in a 56-year-old male. A Axial T1-weighted MR image shows pericholecystic fluid collection (arrow) with rim enhancement secondary to GB perforation. B Axial T2-weighted image shows pericholecystic fluid with restricted diffusion on the
corresponding apparent diffusion coefficient (ADC map) image (C) consistent with abscess (arrow). Pericholecystic fluid can be mistaken for localized GB wall irregularity; therefore, in this situation diffusion-weighted imaging can be very helpful in characterization of pericholecystic fluid as an abscess.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 11. 88-year-old female with cholecystocolonic fistula secondary to chronic GB perforation (Type III). A Axial and B coronal post-contrast CT images show adherent colon and GB with air inside the GB (arrow). C, D Axial post-contrast CT
images show air in the common bile duct (arrow) and intrahepatic biliary radicals (arrowhead) indicating pneumobilia secondary to fistulous communication between the colon and GB.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 12. Gallstone ileus (Type III perforation) in an 85-year-old female with 3-day history of nausea, vomiting, and epigastric discomfort. A, B Axial CT images show air inside the GB (arrow) with an obstructing gallstone in the distal jejunum (arrowhead).
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
79-year-old male with a cholecystoduodenal fistula (Type III perforation). A–C Axial contrast-enhanced CT images show air inside the GB lumen with an air-fluid level (arrow, A). Also, air in the common bile duct (arrowhead, B) and intrahepatic biliary radicals (arrowhead, C) are noted indicative of pneumobilia. Constellation of findings is consistent with cholecystoenteric fistula. D, E Axial and F coronal T2-weighted MR images show an air-fluid level (arrowhead, D) in the GB and clearly outline the fistulous communication (arrows) between the GB and the duodenum (arrowheads, E, F).
bFig. 13.
Fig. 14. 58-year-old male with GB perforation after liver biopsy secondary to iatrogenic trauma. A Axial and B coronal contrast-enhanced CT images show a linear hyperdensity consistent with hemobilia (arrows) and air inside the GB
(arrowheads) consistent with iatrogenic perforation. C Axial and D coronal images from a repeat CT done after 5 days show an increase in the hyperdense material inside the GB indicating increasing hemobilia (asterisk).
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 15. Spilled gallstones. A US of right lobe of liver shows hyperechoic focus with posterior acoustic shadowing (arrow) posterior to right hepatic lobe consistent with spilled gallstones. B Axial post-contrast CT image shows calcified gall-
stones (arrowhead) in the pelvis. C Coronal T2-weighted MR image shows hypointense spilled gallstone (arrow) along the inferior margin of the liver.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 16. Complications of spilled gallstones after cholecystectomy. Infection and resultant inflammatory reaction around spilled gallstones can lead to abscess formation. A CT is useful in detecting calcified spilled gallstones with surrounding ab-
scess (arrow). B Coronal T2-weighted MR image shows fluid in the GB fossa surrounding the residual gallstones (arrows). C An abscessogram performed reveals fistulous communication to the duodenum, a known complication of spilled gallstones.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
b Fig. 17.
Mimics of perforated GB. A Recent biliary instrumentation. Axial post-contrast CT image shows air inside the GB (arrow), edematous GB wall, and pneumobilia (not shown) after recent endoscopic retrograde cholangiopancreatography (ERCP) without a wall defect to suggest perforation. Note the presence of biliary stent (arrowhead). B Vicarious excretion of contrast material. Axial CT image shows vicarious excretion of contrast material and gas-containing stones (arrow) inside the GB that may be mistaken for cholo-enteric fistula. Note persistent renal enhancement from prior contrast administration because of underlying acute tubular necrosis. C, D Emphysematous cholecystitis. Axial (C) and sagittal (D) post-contrast CT images show multiple foci of gas (arrows) seen within mildly thickened GB wall and pericholecystic stranding consistent with emphysematous cholecystitis but no obvious wall defect to suggest perforation. E GB carcinoma. Axial post-contrast CT image shows a large GB intraluminal tumor infiltrating into the adjacent liver parenchyma (arrow) with a necrotic lymph node (arrowhead). Surrounding liver hyperemia suggests inflammation. There is no wall defect or extraluminal gallstone to suggest perforation.
Conclusion GB perforation is a potentially life-threatening condition requiring a high clinical index of suspicion for a preoperative diagnosis. Imaging aids in early detection allowing timely institution of appropriate management thus decreasing morbidity and mortality associated with a delayed diagnosis. As a result, radiologists must be aware of multimodality imaging features as more than one imaging modality may be needed to establish a definitive diagnosis. Acknowledgments. Adeel R. Seyal, MD and Keyur Parekh, MD were supported by educational grant from Siemens Healthcare. We would like to acknowledge Mr. David Botos for his medical illustrations in Fig. 1. Conflict of interest. None were declared.
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39. Date RS, Thrumurthy SG, Whiteside S, et al. (2012) Gallbladder perforation: case series and systematic review. Int J Surg 10(2):63– 68. doi:10.1016/j.ijsu.2011.12.004 40. Halabi WJ, Kang CY, Ketana N, et al. (2013) Surgery for gallstone ileus: a nationwide comparison of trends and outcomes. Ann Surg . doi:10.1097/SLA.0b013e31827eefed 41. Dai XZ, Li GQ, Zhang F, Wang XH, Zhang CY (2013) Gallstone ileus: case report and literature review. World J Gastroenterol 19(33):5586–5589. doi:10.3748/wjg.v19.i33.5586 42. Deshmukh SD, Johnson PT, Sheth S, Hruban R, Fishman EK (2013) CT of gallbladder cancer and its mimics: a pattern-based approach. Abdom Imaging 38(3):527–536. doi:10.1007/s00261012-9907-1 43. Tan CH, Lim KS (2013) MRI of gallbladder cancer. Diagn Interv Radiol 19(4):312–319. doi:10.5152/dir.2013.044 44. Zhao F, Lu PX, Yan SX, et al. (2013) CT and MR features of xanthogranulomatous cholecystitis: an analysis of consecutive 49 cases. Eur J Radiol 82(9):1391–1397. doi:10.1016/j.ejrad.2013.04.026
Abdominal Imaging
Abdom Imaging (2014) DOI: 10.1007/s00261-014-0121-1
Cross-sectional imaging of perforated gallbladder Adeel R. Seyal, Keyur Parekh, Fernanda D. Gonzalez-Guindalini, Paul Nikolaidis, Frank H. Miller, Vahid Yaghmai Department of Radiology, Northwestern Memorial Hospital, Northwestern University-Feinberg School of Medicine, 676 North Saint Clair Street Suite 800, Chicago, IL 60611, USA
Abstract Gallbladder perforation is a potentially life-threatening condition commonly seen as a complication of acute cholecystitis. Urgent surgical intervention is often needed to reduce serious morbidity and mortality. It presents a diagnostic challenge due to nonspecific symptoms, leading to a delay in diagnosis. Imaging plays a vital role in early identification of this potentially fatal condition and evaluation by more than one imaging modality may be required to make the diagnosis. Knowledge of specific and ancillary imaging findings is crucial to avoid misdiagnosis. In this article, we will review the risk factors, pathophysiology, and surgical classification of gallbladder perforation and discuss the role of multimodality imaging in its diagnosis. Differential diagnoses on imaging will also be discussed. Key words: Gallbladder perforation—Computed tomography—Ultrasound—Magnetic resonance imaging—Biliary fistula—Gallstones
Gallbladder (GB) perforation is an uncommon and potentially life-threatening condition, most commonly seen as a complication of acute cholecystitis. With improvements in antibiotic therapies and increasing number of early cholecystectomies, the incidence has dropped in acute cholecystitis from 2% to 15% as cited in the literature from past 50 years [1–3] to 0.8–3.2% in more recent reports [1, 3]. GB perforation may develop as early as 2 days after the onset of acute cholecystitis or up to several weeks later [4, 5]. GB perforation often requires urgent surgical intervention but is rarely diagnosed preoperatively. Clinical differentiation from
Correspondence to: Vahid Yaghmai; email: v-yaghmai@northwestern. edu
uncomplicated acute cholecystitis is often difficult leading to a delay in diagnosis, higher incidence of complications, and poorer outcomes [1, 6, 7]. GB perforation can also be seen as a result of traumatic injury and often follows an insidious clinical course making the diagnosis difficult. It can be easily missed on imaging; thus, delaying management which can lead to substantial morbidity and mortality [8]. Weckner et al. [9] reported 107 patients at autopsy who had died secondary to GB perforation without the diagnosis being suspected. Recent advances in medical imaging have enabled early detection of GB perforation allowing timely institution of appropriate management. The purpose of this article is to provide a comprehensive review of multimodality imaging findings of this potentially fatal abdominal emergency.
Predisposing conditions There is an increased tendency for acute acalculous cholecystitis to progress to perforation, although most cases of GB perforation are associated with calculous cholecystitis because of its higher incidence [10]. GB perforation is typically seen in the setting of diseased GB such as cholecystitis, malignancy and corticosteroid use, and vascular compromise [6]. Diabetes mellitus and atherosclerotic heart disease are also thought to be contributory [4]. Trans-catheter arterial chemoembolization (TACE) can lead to acute ischemic cholecystitis, as a result of non-target embolization of cystic artery [11, 12]. This can progress to GB necrosis and perforation. Similarly, trans-catheter arterial radioembolization (TARE) can cause radiation-induced cholecystitis with rare progression to perforation [13]. Despite the fact that more females are diagnosed with acute uncomplicated cholecystitis [14], perforation is more commonly seen in males [1, 15–17] with elderly
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
patients being particularly susceptible to perforation [7, 18]. An otherwise normal GB can perforate secondary to trauma (iatrogenic, blunt, or penetrating). GB injury is found in 2% of patients with blunt abdominal trauma undergoing laparotomy in association with other visceral injuries (rarely isolated GB injuries occur). Perforation (full-thickness) is the most common form of GB injury in blunt abdominal trauma with the treatment of choice being cholecystectomy [8, 19]. Usually, the GB is protected because of its anatomic location behind the liver and ribs. Certain conditions increase the risk of its perforation in the setting of trauma such as thin-walled normal GB, distended GB in the pre-prandial state, malpositioned GB secondary to cirrhosis, and alcohol consumption which increases sphincter of Oddi tone causing GB distension, thus, making it more prone to injury [20]. Various predisposing factors for GB perforation are listed in Table 1.
Neimeier’s classification of perforated GB In 1934, Neimeier [21] proposed a classification for GB perforation that is still used today and has prognostic implications: Type I, acute free perforation of the GB into the peritoneal cavity without protective adhesions (Fig. 1A); Type II, subacute perforation surrounded by a pericholecystic abscess walled off by adhesions (Fig. 1B); and Type III, chronic perforation with presence of a fistulous communication between GB and a viscus (Fig. 1C). Subacute (type II) perforations are the most common type in most reported series [22, 23] accounting for 60% of all cases; chronic (type III) perforation seen in 30% and acute perforation (type I) in 10%. Type I perforations usually carry a higher mortality. Fletcher et al. reported 40% mortality for type I, 4% mortality for type II. and no mortality for type III perforations [22]. For type III perforations, one-third present with gallstone ileus [6]. Table 1. Predisposing conditions for GB perforation Diseased GB Cholecystitis (acute calculous or acalculous or chronic) Cholelithiasis Systemic diseases (Diabetes mellitus and atherosclerotic heart disease) Drugs (e.g., corticosteroids) Vascular compromise (ischemic injury) Normal GB Trauma (blunt and penetrating) Iatrogenic
Fig. 1. Neimeier’s classification of perforated GB. A Type I: acute free perforation. B Type II: subacute perforation with peri-cholecystic abscess. Gallstone may be seen outside of GB within the abscess. C Type III: chronic perforation with formation of cholecystoenteric fistula.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Pathophysiology One proposed mechanism of GB perforation is impaction of a gallstone in the cystic duct that leads to obstruction and accumulation of bile within the GB causing distension. The presence of intraluminal bile salts causes chemical inflammatory reaction of the GB mucosa. Progressively worsening distension will compromise the vascular supply leading to gangrene, necrosis and perforation of the GB wall [6, 24]. It is believed that Rokitansky–Aschoff sinuses can become dilated by forceful contractions of the GB forming diverticula. Infection of these dilated sinuses may eventually lead to necrosis and perforation of the GB wall [24, 25]. Glenn and Moore [25] proposed this as the likely mechanism for intrahepatic rupture of the GB leading to formation of hepatic abscesses. Focal ischemia of unknown etiology has also been proposed as a mechanism of GB rupture, especially in cases without acute inflammation or gallstones [26]. Perforation can be found in the fundus, body, and the neck of GB although fundus is the most commonly perforated site secondary to its relatively poor blood supply (farthest from the cystic artery thus most prone to ischemic injury) [10, 27].
Clinical manifestations GB perforation often presents a diagnostic challenge. Clinical signs and symptoms depend on the etiology and are usually nonspecific. They can range from right upper quadrant to generalized abdominal pain, tenderness, rigidity ,and guarding (signs of peritonitis) to nonspecific abdominal symptoms (nausea, vomiting, vague upper abdominal discomfort, or pain). Often it is difficult to differentiate GB perforation from uncomplicated acute cholecystitis likely because bile leak from the perforation might be contained [10, 28]. GB perforation in acute cholecystitis should be suspected in patients who become toxic or have sudden clinical deterioration for unexplained reasons [29]. Complications include bile leak and peritonitis;
Table 2. Radiologic features of GB perforation Specific imaging findings Focal defect in GB wall Extraluminal gallstone Ancillary imaging findings Pericholecystic fluid collection/abscesses Thickened irregular GB wall or focal bulge Distended GB Omental or mesenteric fat streaking Pneumobilia
abscesses around the GB fossa, intraperitoneal or intrahepatic; intraperitoneal air; sepsis or septic shock; fistulae; and bowel obstruction [30]. Mortality worsens with a delay in diagnosis. A mortality rate as high as 42% has been reported [25]. However, advances in perioperative management (anesthesiology and intensive care conditions) have reduced the mortality rates to 7–16% [1, 7, 31].
Imaging findings Various imaging features of GB perforation are listed in Table 2. Ultrasound (US) is usually the initial method of investigation of choice in patients with suspected acute cholecystitis or its complications though findings may be non-specific. Chau et al. first described the ‘‘sonographic-hole’’ sign, which is the direct visualization of a GB wall defect on US (Fig. 2). It is a very specific sign of GB perforation that can be seen on US, computed tomography (CT), or magnetic resonance (MR) imaging but is not always visualized [32, 33] (Figs. 3, 4, 5). Kim et al. compared findings on US with CT in 13 patients with surgically confirmed GB perforation and found a wall defect in seven patients on CT and none on US. They concluded that CT is superior to US for the diagnosis of GB perforation because of its ability to better demonstrate a focal wall defect [23]. Finding gallstones outside of the GB is also specific for GB perforation in the correct clinical setting. Interruption of the GB wall and extraluminal radio-opaque gallstones is usually better appreciated on CT [6, 33] (Fig. 6). Gas within gallstones (‘‘Mercedes Benz’’ sign) outside of the GB may be present and can facilitate the diagnosis of GB perforation on CT or MR imaging [6] (Fig. 7). A focal bulge in the GB wall has been described as a sign of GB rupture [6, 23]. Mesenteric or omental fat streaking is another ancillary finding of GB perforation seen on CT. Subacute GB perforations (Type II) are usually contained by a pericholecystic abscesses. They appear as complex echogenic pericholecystic fluid collections on US usually in the presence of a thickened hypoechoic edematous GB wall and cholelithiasis. CT further helps to identify and evaluate the location and extent of such abscesses (Fig. 8). On contrast-enhanced T1-weighted MR images, pericholecystic or intrahepatic abscesses appear as fluid collections with rim enhancement (Fig. 9) [34]. Low signal on apparent diffusion coefficient (ADC) map images reflecting restricted diffusion can help in characterization of pericholecystic fluid as an abscess (Fig. 10). In chronic (Type III) perforations, there is formation of cholecystoenteric fistula secondary to chronic inflammation of the GB and its proximity to the intestine. Once
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 2. 69-year-old female with perforated acute gangrenous cholecystitis (Type I perforation). A, B Longitudinal and C transverse GB US images show focal wall defect (arrow) and
sloughed membranes (arrowheads). D Sagittal reformatted CT image shows a visible wall defect (arrow). Gangrenous change is seen in up to 30% of patients with acute cholecystitis.
a fistulous communication is established, air can pass from the intestine to the GB and biliary tree causing pneumobilia (Fig. 11). Also, gallstones can pass through to the bowel frequently causing obstruction (gallstone ileus), most often in the ileum followed by jejunum. Most obstructing gallstones are at least 2.5 cm in diameter. The terminal ileum is the narrowest part of the small intestine and therefore the most likely site of obstruction. Rarely, gallstones can obstruct other parts of the gut such as duodenum or pylorus causing gastric outlet obstruction (Bouveret’s syndrome). The classic radiologic sign for gallstone ileus is the ‘‘Rigler’s triad’’ (pneumobilia, mechanical bowel obstruction, and an ectopic gallstone), which can be seen in 14.8% of cases on abdominal radiographs but up to 77.8% cases on CT [35]
(Fig. 12). CT can accurately show the fistula and the degree and level of bowel obstruction [36]. MR imaging can be also useful in identifying the fistulous communication (Fig. 13). For traumatic GB rupture (blunt, penetrating, or iatrogenic), CT is most effective for diagnosis as it is usually done initially in a trauma setting (Fig. 14). Imaging findings on CT and MR include a collapsed GB despite prolonged fast (which would distend the GB); disruption of the GB wall; intraluminal hemorrhage (hemobilia); complex pericholecystic fluid collections; omental or mesenteric fat streaking; and thickened and edematous GB wall [19, 20]. US findings in traumatic GB rupture may include a collapsed GB despite prolonged fast, disruption of the GB wall with focal loss of
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 3. Acute free perforation of the GB (Type I) in a 51-yearold male with acute cholecystitis. A Initial presentation axial CT post contrast with B coronal reformat show distended GB with surrounding liver hyperemia suggestive of cholecystitis
(arrows). C Axial and D coronal images of CT performed after 4 days because clinical deterioration shows GB wall defect (arrows) with extensive pericholecystic inflammatory changes (asterisk) consistent with acute perforation.
its reflectivity, highly echogenic intraluminal contents, complex echogenic pericholecystic fluid and a thickened, hypoechoic GB wall [20]. Though all of these findings may not be present, their identification helps in making the diagnosis in suspected cases. Spilled gallstones can be seen as a complication of cholecystectomy as a result of iatrogenic GB perforation. They are most commonly seen around the liver, GB fossa, Morrison’s pouch, pelvis, and port sites. They are encountered in approximately 7% (but as many as 30%) of laparoscopic cholecystectomies secondary to GB perforation during surgical dissection and extraction [37]. US shows mobile hyperechoic foci with posterior acoustic shadowing (Fig. 15A). With superimposed infection, abscesses may form around gallstones, which
appear as hyperechoic foci (gallstones) within hypoechoic fluid collections. On CT, stones with higher calcium content appear as high attenuation foci, whereas pure cholesterol stones and those with low calcium content may go undetected (Fig. 15B). On MR, pigmented gallstones appear hyperintense on T1-weighted images whereas others are typically hypointense on both T1- and T2-weighted images (Fig. 15C). CT and MR imaging (Fig. 16) can show inflammatory reaction or fluid collections around the spilled gallstones. Less frequently, spilled gallstones can erode and migrate through the abdominal wall, diaphragm, and gastrointestinal tract forming fistula (Fig. 16C). All efforts should be made to retrieve spilled gallstones during laparoscopic cholecystectomy, whereas infected retained gallstones should be
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
57-year-old male with large intrahepatic abscess secondary to subacute (Type II) perforation of the GB. A US (longitudinal view) of the GB (asterisk) and right hepatic lobe shows a large intrahepatic fluid collection (arrow) containing multiple hyperechoic foci (arrowhead) with posterior acoustic shadowing consistent with gallstones. B Axial noncontrast CT shows pericholecystic fluid collection (arrow) and mesenteric fat stranding (asterisk). C Axial T1-weighted post-contrast MR images show GB wall defect (arrow), extraluminal hypointense gallstones (arrowhead) within an adjacent intrahepatic abscess. D Axial T1-weighted post contrast and E T2weighted MR image shows large intrahepatic fluid collection (arrow) with restricted diffusion on ADC map F consistent with multiloculated intrahepatic abscess formation.
b Fig. 4.
CT-guided GB drainage) can be employed with elective cholecystectomy depending on the condition of the patient [31, 39]. Chronic perforations are usually diagnosed in symptomatic patients. For gallstone ileus (type III perforation), enterolithotomy with stone extraction is generally performed due to its low incidence of complications. Cholecystectomy may be performed at the time of initial surgery or at a later date. Also, fistula repair can be undertaken at the time of surgery depending on the condition of the patient though spontaneous closure of fistula can be seen in greater than 50% of the cases [40, 41].
Mimics of perforated GB surgically removed to prevent recurrent infections [37, 38].
Management highlights Cholecystectomy, drainage of abscess if present, antibiotics, and peritoneal lavage are considered the mainstays of treatment of GB perforation [16]. For acute (type I) perforations, urgent open or laparoscopic cholecystectomy or cholecystostomy is done. Management of subacute (type II) perforations is relatively more complex with lack of consensus in the published literature. If the patient is fit for surgery, cholecystectomy (open or laparoscopic) is recommended. For patients who are critically ill or otherwise unfit for surgery, less invasive options (percutaneous US- or
Fig. 5. 69-year-old male with perforated GB (Type II perforation) after recent TARE (Yttrium-90) of the right liver lobe for metastatic pancreatic cancer with neuroendocrine differentiation. Axial contrast-enhanced CT image shows distinct GB wall defects (arrows) with surrounding pericholecystic fluid.
A high index of clinical suspicion and knowledge of multimodality imaging features is necessary to diagnose GB perforation and differentiate it from other conditions with overlapping imaging findings. In addition, relevant clinical history is essential for accurate diagnosis. Pneumobilia and air within the GB is suspicious for perforation but can be seen with recent biliary instrumentation. Presence of gas-containing gallstones inside the GB can mimic cholecystoenteric fistula but may lack any other signs of GB perforation (Table 2). Intramural air (emphysematous cholecystitis), sloughing of GB mucosa (gangrenous cholecystitis), and infiltrating GB cancer without obvious wall defects should be carefully evaluated to avoid misdiagnosis of GB perforation (Fig. 17). It can be challenging to differentiate GB perforation with pericholecystic abscess from GB carcinoma or xanthogranulomatous cholecystitis. GB cancer can appear on cross-sectional imaging as an intraluminal polypoid mass, wall thickening (focal or diffuse), or a mass replacing the GB [42]. It is usually T1 hypointense and T2 hyperintense when compared with the surrounding liver. On postcontrast MR, GB cancer shows early irregular enhancement that persists into delayed images [43]; whereas, pericholecystic abscess typically shows postcontrast rim enhancement. Coexistence of diffusely thickened GB wall, continuous mucosal line with surface enhancement, hypodense intramural nodules, and cholelithiasis on crosssectional imaging is suggestive of xanthogranulomatous cholecystitis. Detecting fat within the intramural nodules on chemical-shift MR imaging further aids in the diagnosis of xanthogranulomatous cholecystitis [44]. Extensive inflammatory changes in the GB fossa secondary to duodenal ulcer perforation can obscure the anatomy of the region necessitating careful GB evaluation. Also, it can be challenging to confidently diagnose GB perforation in abdominal trauma patients with liver laceration and fluid in the region of the GB fossa.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder b Fig. 6.
Extraluminal gallstones and liver abscess in an 87year-old male with subacute (Type II) perforation of the GB. A–C Axial noncontrast CT images show multiple gallstones within the GB (arrow, A), pericholecystic/intrahepatic abscess (arrowhead), and irregular contour of GB fundus (arrow, B). Extraluminal gallstones (arrow, C) are noted. D Coronal reformatted image shows free fluid (asterisk) and extraluminal gallstones (arrows). E Sagittal reformatted image shows extraluminal gallstone (arrow), intrahepatic abscess (arrowhead), and extensive mesenteric fat stranding (asterisk).
Fig. 7. 56-year-old male with a duodenal gallstone secondary to a cholecystoduodenal fistula (Type III perforation). A Axial contrast-enhanced CT image shows a 1.6 cm gallstone (arrow) within the GB. B Coronal CT image from a repeat scan after 3-months shows the same gallstone now in proximal duodenum (arrow) with pneumobilia (arrowhead) and stranding in the GB fossa. C Axial and D coronal T2-
weighted MR images show a hypointense duodenal gallstone (arrow) with a normal caliber common bile duct (arrowhead, C) and without imaging evidence of small bowel obstruction. Note the Mercedes-Benz sign (air within the gallstone) (arrowhead, D). Presence of gas within the extraluminal gallstones helps diagnose gallstone within duodenum and GB perforation.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 8. 70-year-old male with large pericholecystic fluid collections and extraluminal gallstones secondary to a perforated GB (Type II perforation). A, B US images (longitudinal views) show large pericholecystic fluid collections (arrow). Note the presence of an extraluminal gallstone (arrowhead, A). A large gallstone is seen inside the GB (asterisk, B). C Axial and D sagittal post-contrast CT images show pericholecystic fluid collections (arrows), edematous GB wall with surrounding liver hyperemia (arrowhead, D). A focal wall
defect in the GB wall is clearly seen in the axial image, communicating with a pericholecystic fluid collection (arrowhead, C). E, F Axial T2-weighted MR images show large intraluminal gallstones (arrows) and multiple hypointense gallstones adjacent to a focal wall defect (arrowhead, F). G Photograph of the GB specimen after cholecystectomy shows an area of perforation (arrow) with a protruding gallstone. Note the two large gallstones and their corresponding appearance on MR images (E, F).
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 8.
continued
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 9. 58-year-old-female with pericholecystic multiloculated abscess secondary to perforated GB (Type II perforation). A Axial and B coronal T1-weighted post-contrast MR images with fat saturation show multiloculated pericholecystic fluid
with enhancing walls (arrows) consistent with multiloculated abscess. C Axial and D coronal T2-weighted MR images show hyperintense loculated pericholecystic fluid collection (arrows). A gallstone is seen in the GB (arrowhead, C).
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 10. Perforated GB with pericholecystic abscesses (Type II perforation) in a 56-year-old male. A Axial T1-weighted MR image shows pericholecystic fluid collection (arrow) with rim enhancement secondary to GB perforation. B Axial T2-weighted image shows pericholecystic fluid with restricted diffusion on the
corresponding apparent diffusion coefficient (ADC map) image (C) consistent with abscess (arrow). Pericholecystic fluid can be mistaken for localized GB wall irregularity; therefore, in this situation diffusion-weighted imaging can be very helpful in characterization of pericholecystic fluid as an abscess.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 11. 88-year-old female with cholecystocolonic fistula secondary to chronic GB perforation (Type III). A Axial and B coronal post-contrast CT images show adherent colon and GB with air inside the GB (arrow). C, D Axial post-contrast CT
images show air in the common bile duct (arrow) and intrahepatic biliary radicals (arrowhead) indicating pneumobilia secondary to fistulous communication between the colon and GB.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 12. Gallstone ileus (Type III perforation) in an 85-year-old female with 3-day history of nausea, vomiting, and epigastric discomfort. A, B Axial CT images show air inside the GB (arrow) with an obstructing gallstone in the distal jejunum (arrowhead).
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
79-year-old male with a cholecystoduodenal fistula (Type III perforation). A–C Axial contrast-enhanced CT images show air inside the GB lumen with an air-fluid level (arrow, A). Also, air in the common bile duct (arrowhead, B) and intrahepatic biliary radicals (arrowhead, C) are noted indicative of pneumobilia. Constellation of findings is consistent with cholecystoenteric fistula. D, E Axial and F coronal T2-weighted MR images show an air-fluid level (arrowhead, D) in the GB and clearly outline the fistulous communication (arrows) between the GB and the duodenum (arrowheads, E, F).
bFig. 13.
Fig. 14. 58-year-old male with GB perforation after liver biopsy secondary to iatrogenic trauma. A Axial and B coronal contrast-enhanced CT images show a linear hyperdensity consistent with hemobilia (arrows) and air inside the GB
(arrowheads) consistent with iatrogenic perforation. C Axial and D coronal images from a repeat CT done after 5 days show an increase in the hyperdense material inside the GB indicating increasing hemobilia (asterisk).
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 15. Spilled gallstones. A US of right lobe of liver shows hyperechoic focus with posterior acoustic shadowing (arrow) posterior to right hepatic lobe consistent with spilled gallstones. B Axial post-contrast CT image shows calcified gall-
stones (arrowhead) in the pelvis. C Coronal T2-weighted MR image shows hypointense spilled gallstone (arrow) along the inferior margin of the liver.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
Fig. 16. Complications of spilled gallstones after cholecystectomy. Infection and resultant inflammatory reaction around spilled gallstones can lead to abscess formation. A CT is useful in detecting calcified spilled gallstones with surrounding ab-
scess (arrow). B Coronal T2-weighted MR image shows fluid in the GB fossa surrounding the residual gallstones (arrows). C An abscessogram performed reveals fistulous communication to the duodenum, a known complication of spilled gallstones.
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
A. R. Seyal et al.: Cross-sectional imaging of perforated gallbladder
b Fig. 17.
Mimics of perforated GB. A Recent biliary instrumentation. Axial post-contrast CT image shows air inside the GB (arrow), edematous GB wall, and pneumobilia (not shown) after recent endoscopic retrograde cholangiopancreatography (ERCP) without a wall defect to suggest perforation. Note the presence of biliary stent (arrowhead). B Vicarious excretion of contrast material. Axial CT image shows vicarious excretion of contrast material and gas-containing stones (arrow) inside the GB that may be mistaken for cholo-enteric fistula. Note persistent renal enhancement from prior contrast administration because of underlying acute tubular necrosis. C, D Emphysematous cholecystitis. Axial (C) and sagittal (D) post-contrast CT images show multiple foci of gas (arrows) seen within mildly thickened GB wall and pericholecystic stranding consistent with emphysematous cholecystitis but no obvious wall defect to suggest perforation. E GB carcinoma. Axial post-contrast CT image shows a large GB intraluminal tumor infiltrating into the adjacent liver parenchyma (arrow) with a necrotic lymph node (arrowhead). Surrounding liver hyperemia suggests inflammation. There is no wall defect or extraluminal gallstone to suggest perforation.
Conclusion GB perforation is a potentially life-threatening condition requiring a high clinical index of suspicion for a preoperative diagnosis. Imaging aids in early detection allowing timely institution of appropriate management thus decreasing morbidity and mortality associated with a delayed diagnosis. As a result, radiologists must be aware of multimodality imaging features as more than one imaging modality may be needed to establish a definitive diagnosis. Acknowledgments. Adeel R. Seyal, MD and Keyur Parekh, MD were supported by educational grant from Siemens Healthcare. We would like to acknowledge Mr. David Botos for his medical illustrations in Fig. 1. Conflict of interest. None were declared.
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