Gaslrointest Radiol 17:24-26 (1992)

Gastrointestinal

Radiology 9 Springer-Verlag New York Inc. 1992

Gallbladder Perforation: Preoperative Diagnosis by Combined Imaging Techniques Anastasios A. Mihas, 1 Geoff Lewis, 1 Mohammad Athar, 2 and Menahen Shueke 1 Departments of 1Medicine and -'Radiology, VA Medical Center and University of Mississippi School of Medicine, Jackson, Mississippi, USA

Abstract. Gallbladder perforation represents the most serious complication of cholecystitis. Rapid preoperative diagnosis is necessary because of the high morbidity and mortality associated with it. The authors present a case of gallbladder perforation in a 64-year-old man who had been on high doses of steroids. This case was diagnosed preoperatively by combined radiologic imaging methods. Key words: Gallbladder, p e r f o r a t i o n - Bile leakage, diagnosis.

Acute gallbladder perforation is a potentially lethal condition occurring in approximately 10% of cases of cholecystitis that come to surgery [1-3]. Since its original description by Duncan in 1844 [4] and the classification by Neimeier in 1934 [5], gallbladder perforation has been regarded by clinicians with great fear because of its increased morbidity and mortality [6-7]. The higher mortality rate (15-30%) has been attributed to a delay in establishing the diagnosis, thus leading to delayed therapeutic intervention. The purpose of this paper is to report a patient receiving high-dose steroids and in whom gallbladder perforation was diagnosed preoperatively by a combination of imaging techniques.

Case Report A 64-year-old man with chronic obstructive pulmonary disease (COPD) who had recently completed a course of prednisone therAddress offprint requests to: A.A. Mihas, M.D., VA Medical Center ( l l l A ) , 1500 E. Woodrow Wilson Blvd., Jackson, MS 39216, USA

apy was admitted to the hospital for an exacerbation of his COPD. He also complained of right upper quadrant myalgia which he attributed to lifting a crate of tomatoes 2 weeks earlier. Abdominal examination revealed mild right upper quadrant tenderness, normoactive bowel sounds but no rebound. Initial laboratory studies showed a hematocrit of 43% and a leukocyte count of 25.100/mm 3 with 95% segmented forms, 1% bands, and 2% lymphocytes. Other laboratory data were within normal limits, including liver enzymes. Antibiotics, nebulized beta agonist, and intravenous methylprednisolone 40 mg q 12 h were given. The following day, the patient had recurrent right upper quadrant pain and a temperature of 38~ Supine and upright abdominal radiographs revealed no free air or signs of obstruction. An abdominal ultrasound revealed several small gallstones within a moderately distented gallbladder with somewhat thickened and irregular walls (Fig. 1). Abdominal computed tomography (CT) disclosed the presence of loculated fluid along the lateral and posterior aspects of the right lobe of the liver. In addition, a small amount of fluid was found in the gallbladder fossa (Fig. 2). These findings were felt to be suggestive of a possible gallbladder perforation and therefore a hepatobiliary scan was performed using technetium-99m iminodiacetric acid (Tc-99m IDA). There was a delay in the visualization of the gallbladder but both cystic and common bile ducts were patent. However, there was accumulation of significant amounts of the radionuclide along the lateral aspect of the right lobe of the liver. This corresponded to the area of loculated fluid collection seen on the CT scan, indicating the presence of bile leakage (Fig. 3). At surgery, he was found to have a perforated gallbladder with numerous intraperitoneal gallstones and a bile collection along the fight lateral aspect of the liver. A cholecystectomy was performed but an intraoperative cholangiogram could not be obtained due to a small cystic duct. However, no palpable stones were found in the entire biliary tract. The patient's postoperative course was uneventful.

Discussion Perforation of the gallbladder is the most serious complication of acute cholecystitis that is not often diagnosed preoperatively [6, 7]. According to the classification proposed by Niemeier [5], gallbladder perforation can be either (a) acute with free bile into

A.A. Mihas et al.: Gallbladder Perforation

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Fig. 1. A gallbladder sonogram shows multiple small gallstones with acoustic shadowing larrows). Gallbladder wall is slightly thickened and irregular in outline.

Fig. 2. CT of the upper abdomen showing small amount of loculated fluid in the hilus and lateral to the right lobe of the liver (arrowsl.

Fig. 3. Tc-99m IDA scan at 20 rain demonstrating leakage of radionuclide outside the gallbladder and its accumulation lateral to the right lobe of the liver (arrows), GB, gallbladder: D, duodenum.

the peritoneal cavity and generalized peritonitis, (b) subacute with formation of a pericholecystic abscess, or (c) chronic, into a hollow viscus with cholecystenteric fistula formation. Our case clearly falls into the second category of subacute perforation as shown on CT scan, hepatic scintigraphy, and confirmed at surgery. As observed in our case, the most frequent site of gallbladder perforation is the fundus. The reason for this anatomic location of perforations is not clear but vascular compromise of the gallbladder fundus has been incriminated by various authors [8]. I n most cases, it occurs as a complication of acute cholecystitis due to stone impaction of the cystic duct, with subsequent mucosal inflammation and eventual vascular compromise that result in ischemia and gangrene [9]. Our patient, however, did not have acute cholecystitis as was shown by the patency of the cystic duct on hepatobiliary scintigraphy. Therefore, stone impaction in the cystic duct as a putative mechanism of vascular compromise and perforation is highly unlikely. By contrast, the large doses of steroids may have contributed to the perforation of his gallbladder and also modified the clinical picture

similarly to that seen with perforations of gastrointestinal tract. Our case illustrates the value of pursuing the diagnosis of gallbladder perforation with a combination of radiologic techniques. It must be kept in mind, however, that findings on most of these imaging modalities are not always pathognomonic [10, 1I] and more invasive tests, such as endoscopic retrograde cholangiography may be necessary [12]. In our case, we were fortunate enough to confirm the suspicions aroused by the CT scan for possible gallbladder perforation by the radionuclide leakage seen on hepatobiliary scintigraphy. Acknowledgment. The authors wish to thank Lara Tuggle for typing the manuscript.

References 1. Williams NF, Scobie TK. Perforation of the gallbladder: analysis of 19 cases. Can Med Assoc J 1976;115:1223-1225 2. Roslyn J J, Thompson JE Jr, Darvin H, et al. Risk factors for gallbladder perforation. A m J Gastroenterol 1987;82:636-640

26 3. Simmons TC, Miller C, Weaver R. Spontaneous gallbladder perforation. Am Surg 1989;55:311-313 4. Duncan J. Femoral hernia, gangrene of the gallbladder: extravasation of bile: peritonitis: death. North J Med 1844;2:1151-1153 5. Niemeier OW. Acute free perforation of the gallbladder. Ann Surg 1934;99:922-924 6. Roslyn JJ, Busuttil RW. Perforation of the gallbladder: a frequently mismanaged condition. A m J Surg 1979;137:307-312 7. Show JHF. Bile peritonitis secondary to perforation of the gallbladder: a review of the Dunedin experience 1955-1979. N Z Med J 1980;91:171-173 8. Abu-Dalu J, Urca I. Acute cholecystitis with perforation into the peritoneal cavity. Arch Surg 1971 ;102:108-110

A.A. Mihas et al.: Gallbladder Perforation 9. Isch JH, Finneran JC, Nahrwold DL. Perforation of the gallbladder, A m J Gastroenterol 1971;55:451-458 10. Smith R, Rosen JM, Alderson PO. Gallbladder perforation: diagnostic utility of cholescintigraphy in suggested subacute or chronic cases. Radiology 1986;158:63-66 11. Yeo E, Chen DCP, Siegel MF. Hepatobiliary and gallium imaging findings in gallbladder perforation: a case report and review of the literature. Clin Nucl Med 1989;14:77-81 12. Gilmore PR, Katz NM, Vincent ME, et al. Preoperative diagnosis of gallbladder perforation by endoscopic retrograde cholangiography. Gastrointest Endosc 1989;35:50-54 Received: April 16, 1991; accepted: May 14, 1991

Gallbladder perforation: preoperative diagnosis by combined imaging techniques.

Gallbladder perforation represents the most serious complication of cholecystitis. Rapid preoperative diagnosis is necessary because of the high morbi...
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