Jaundice as a sign of delayed gall- bladder perforation following blunt abdominal trauma J. W. L. Fielding Senior House Officer, Dudley Road Hospital, Birmingham
C. J. L. Strachan Senior Surgical Registrar, Dudle y Road Hospital, Birmingham Summary
A case of delayed rupture of the gall-bladder following
blunt abdominal trauma is presented. A discussion of the aetiology, clinical and biochemical manifestations, and prognosis of this condition follows.
INTRODUCTION PERFORATIONof the gall-bladder
following blunt abdominal trauma is uncommon; Schecter (1969) collected 110 cases in his review of the literature. When the gall-bladder alone is injured, it presents with generalized or right-sided abdominal pain and local tenderness in the right hypochondrium. Frequently, other visceral injuries mask the picture, and, in the absence of diagnostic biochemical or radiological features, an accurate diagnosis is seldom made before laparotomy. The following case emphasizes the value of jaundice as a sign of late perforation of the gallbladder following trauma. The role of liverfunction tests and radiology is discussed.
he was on full diet but he remained pyrexial. The next day he began to complain of right hypochondria1 pain. The serum amylase was normal. In retrospect, the plain X-ray film of the abdomen did show a softtissue mass indenting the transverse colon in the right hypochondrium (Fig. 1). Because his general condition was good, he was treated with cephalosporin (Keflin), and observed. Further improvement followed until, on the tenth day, the right hypochondria1 pain became severe. He was jaundiced and had bile in his urine; a direct Coombs’ test was negative. An aortogram showed a normal hepatic vascular tree and confirmed the left-sided retroperitoneal haematoma. At laparotomy he had biliary peritonitis, which arose from a 2-cm hole in the fundus of a thin-walled gall-bladder. No gall-stones were found. Cholecystectomy was performed. Following operation, he made a good recovery. His bilirubin fell from 60 pmol/l to 12 umol/l over 18 days and his alkaline phosphatase rose from 125 i.u./l to 208 i.u./l over the same period. He was discharged 4 weeks after admission.
COMMENT CASE REPORT A 48-year-old male was admitted to hospital following a serious assault. He had also been drinking. Clinically, he had a fracture of the anterior fossa of the skull and left-sided abdominal bruising. Urinalysis was normal. Thirty-six hours after admission he developed secondary to a left-sided retroparalytic ileus, peritoneal haematoma, which required a blood transfusion. By the fourth day the ileus had gone and
A search of the literature shows that gall-bladder injury occurs in two groups of persons: children below the age of 10 and, more commonly, men under the influence of alcohol. The gall-bladder may be injured by a blow sustained in a road accident, in a fall, or in an assault. The gall-bladder must be distended at the time of injury: alcohol, a common feature of the second group, appears to produce an increase
in pressure in the bile-duct (Pirola and Davis, 1968) and consequent distension of the gallbladder. Rupture is either immediate or delayed, the latter being exceedingly rare. Three cases (Hicks, 1944; Brickley et al., 1960) of late rupture have been reported in the literature before this case. This late rupture may be the result of contusion, or possibly the late extravasation of bile from an injured gall-bladder that has become sealed by an omental wrapping.
Previously no radiological features have been described that are specific for this injury. In this case there was a right hypochondria1 mass, indenting the colon, present on the plain abdominal X-ray. This may be a significant radiological appearance in gall-bladder injury. Certainly right hypochondria1 pain and tenderness, jaundice with bile in the urine, the radiological picture and the biochemical findings should be indicative of rupture of the gall-bladder. The overall mortality rate from biliary peritonitis is 40-70 per cent (MacDonald, 1966; Ellis and Adair, 1974). However, it is only S-10 per cent (Schecter, 1969) when associated with traumatic perforation of the gall-bladder. Such perforation occurs in young people and produces a sterile biliary peritonitis; it is probably these facts, and particularly the latter, that account for the lower mortality. The case presented confirms the difficulty of making this diagnosis, but emphasizes the importance of biochemical and radiological aids to diagnosis.
Fielding and Strachan
Acknowledgements We wish to thank Mr P. G. Bevan and Mr C. P. C. Cotterill, under whose care this patient was. We would also like to thank Miss J. McCulloch for help with the photography, and Mrs V. J. Allen for typing the manuscript.
Straight X-ray of the abdomen, showing a soft-tissue mass in the right hypochondrium, indenting the tranverse colon.
BR~CKLEYH., KAPLAN A., FREEARK R. J. and BROCCOLO E. (1960) Immediate and delayed rupture of the extrahepatic biliary tract following blunt abdominal trauma. Am. J. hug. 100, 107. _ ELLIS H. and ADAIR H. (1974) Bile neritonitis-A
Jaundice was a helpful diagnostic feature in this case. The presence of jaundice has only been recorded in one other case (Brickley et al., 1960). McCarthy and Picazo (1968), in their study of biliary peritonitis, produced mainly by leaking T-tubes, reported that the serum bilirubin rose initially owing to peritoneal absorption, whilst the alkaline phosphatase was normal. Later the alkaline phosphatase rose and the bilirubin returned to normal. This early rise of bilirubin suggests that jaundice should be a common feature of biliary peritonitis.
HICKS J. (1944) A case of traumatic perforation of the gall-bladder in a child. Br. J. Surg. 31, 305. MCCARTHYJ. and PICAZO J. (1968) Bile peritonitis, diagnosis and course. Am. J. Surg. 116, 664. MACDONALD J. A. (1966) Perforation of the gallbladder associated with acute cholecystitis. Ann.
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PIROLA R. C. and DAVIS A. E. (1968) Effects of alcohol on sphincteric resistance at the choledochoduodenal junction in man. Gut 9, 557. SCHECTERD. C. (1969) Solitary wounding of the gallbladder from blunt abdominal trauma. N. Y. State J. Med. 2895.
W. L. Fielding, Esq., 21 Jordan Way, Aldridge, Staffordshire.