Year : 1996 | Volume
: 2 | Issue : 3 | Page : 142--145
Gallbladder perforation: An Asir regional experience and limited
Department of Surgery, College of Medicine, King Saud University, Abha Branch, Abha, Saudi Arabia
Department of Surgery, College of Medicine, King Saud University, Abha Branch, P.O. Box 641, Abha
Acute gallbladder perforation, an infrequent though not uncommon complication of Cholelithiasis and acalculus cholecystitis is reviewed using as materials 16 Arab patients (6 males and 10 females; one Egyptian and 15 Saudis) with gallbladder perforation among 952 patients who had undergone cholecystectomy in Asir Central Hospital between 1990 and 1994. The presentation, method of diagnosis and treatment modalities are compared with recent literature review findings. Since cholecystitis (calculus and acalculus) is a common pathology in Saudi Arabia a preoperative awareness of this complication of the disease will improve diagnosis and minimize morbidity and mortality of gallbladder perforation.
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Jastaniah S. Gallbladder perforation: An Asir regional experience and limited.Saudi J Gastroenterol 1996;2:142-145
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Jastaniah S. Gallbladder perforation: An Asir regional experience and limited. Saudi J Gastroenterol [serial online] 1996 [cited 2020 Feb 22 ];2:142-145
Available from: http://www.saudijgastro.com/text.asp?1996/2/3/142/34019
Acute gallbladder perforation is an infrequent, although not uncommon, complication of cholecystitis and cholelithiasis. It is rarely diagnosed preoperatively, although with a high index of suspicion leading to certain diagnostic procedures preoperatively, the preoperative diagnosis can be confirmed intraoperatively. The delay in making the definitive diagnosis usually accounts for the increased incidence of morbidity and mortality associated with this complication  .
An awareness of this infrequent complication of biliary disease may alert the nonsuspecting surgeon to its diagnosis preoperatively and minimize morbidity and mortality of the condition especially in an area like Saudi Arabia with a high incidence of biliary lithiasis.
Patients and Methods
The medical records of all patients who underwent cholecystectomy during the period 1990-94 at Asir Central Hospital (ACH) were reviewed. The demographics, symptoms and signs, white blood cell count (WBC), bilirubin level, ultrasonographic (US) findings and results of operation of the patients who had gallbladder perforation were analyzed in order to determine the risk factors that may be associated with this complication of biliary disease. All patients with history of trauma and findings of gallbladder perforation preoperatively or intraoperatively were excluded from this study. Associated illnesses like diabetes mellitus and renal failure in the patients were noted and the mortality rate was calculated noting especially the age of the patients who died and their associated illnesses.
Nine hundred and fifty-two patients underwent cholecystectomy during the period under review; 16 of them had perforation of the gallbladder. Of the 16 patients, six were males and 10 were females age ranging between 33 and 120 years with a mean age of 71.6 years, a median age of 70-75 years and a mode of 60 years. All the patients were Arabs, with one Egyptian and 15 Saudis. The symptoms and signs are as illustrated in [Figure 1] with abdominal pain and tenderness common in all the 16 (100%) patients and jaundice present in only four (25%) of them. The WBC ranged in value (cells per deciliter) between 3.5 and 35.8 with an average count of 11.1, a median of 9.1/9.4 and a mode of 6.4. Total bilirubin values in these patients (milligrams percent) ranged from 0.3 to 8.4 with a mean of 2.6, a median of 0.9-1.6 and a mode of 0.7. Peritoneal fluid obtained preoperatively per paracentesis was positive for bile in three. All the patients had ultrasonographic findings of cholelithiasis. Choledocholithiasis was diagnosed ultrsonographically in six patients including two patients with renal failure, both of whom died.
Two of the patients were reported as showing perforated gallbladder in the ultrasonographic study. One was reported as having ascites and four were reported as demonstrating intraabdominal collection (three of them in the subhepatic area). The three patients who died were 60, 10 and 75 years old respectively (a mortality rate of 18.75%); two of them had renal failure.
The incidence of perforation of the gallbladder was 1.7% among cholecystectomized patients in this area. The pathologic characteristics of the gallbladder was not commented upon by our pathologists but there was no patient with acalculus cholecystitis. Predisposing factors in the literature that contribute to perforation of the gallbladder include acute acalculus cholecystitis , ; emphysematous cholecystitis  ; gangrenous cholecystitis  ; cystic duct obstruction  ; multiple cholelithiasis, chronic cholelithiasis  ; and morphine sulfate injection  . Carcinoma of the pancreas has been reported to present with perforation of the gallbladder  . Roslyn et al  have worked out some clinical profiles of patients prone to develop perforation of the gallbladder, one of which is existing systemic disease. Three of the 16 patients (37.5%) had diabetes mellitus, and two had renal failure, both of whom had choledocholithiasis and died postoperatively.
Ultrasonography has been found to be very helpful in making a preoperative diagnosis of gallbladder perforation  . Patients with gallbladder perforation were found by Forsberg et al  to have a slightly thicker gallbladder wall (7 mm; range 3-20 mm) when compared with the uncomplicated cases of acute cholecystitis (5.3 mm; range of 2-13 mm); localized fluid collection in the wall of a gallbladder was seen in a patient just prior to perforation. It was however not possible to find a common sign characteristic for imminent perforation. A combination of ultrasonographic and computed tomographic (CT) scanning could help in the preoperative diagnosis of perforation of the gallbladder  . Some of the combined US and CT scan findings suggestive of gallbladder perforation include fluid and abscess outside the gallbladder ranging from 1-2 mm pericholecystic fluid collection to large phlegmonous masses. A right upper quadrant mass on plain abdominal radiograph and scattered calcification in a patient suspected of perforation of the gallbladder can also be pathognomonic  . Patients with symptoms less than 48 hours before US who were operated upon within 24 hours from the US studies who had US findings of pericholecystic fluid collection, free peritoneal fluid, disappearance of the gallbladder wall echoes, focal highly echogenic areas with acoustic shadows in the gallbladder or inhomogenous, generally echo-poor gallbladder wall have been found to have gallbladder perforation  . Four (25%) of the patients presented with free preoperative peritoneal fluid, three of them bilious on preoperative paracentesis.
Cholescintigraphy and ultrasonography are relatively insensitive for the detection of gallbladder perforation although cholescintigraphy criteria of perforation found in 50% of the patients studied by Swayne and Filipponse  include free spill, pericholecystitis hepatic activity, scintigraphic gallstone ileus sign; sonographic criteria of perforation by the same authors include pericholecystic fluid and pneumobilia with gallstone. Technetium 99 m labeled iminodiacetic acid  and endoscopic retrograde cholangiopancreatography (ERCP)  have also been used in the diagnosis of gallbladder perforation. In a patient with cholelithiasis and symptoms and signs of perforation [Figure 1] with some of the ultrasonographic findings mentioned above, a paracentesis abdominis yielding bilious fluid is a confirmatory sign for the diagnosis of gallbladder perforation.
Differential diagnoses in patients with gallbladder perforation include malrotation of the bowel  ; acalculus cholecystitis  ; and bowel activity with a false-negative result in a morphine-augmented cholescintigraphy  . An uncommon complication of cholecystitis and cholelithiasis, gallbladder perforation has been classified into acute (Type 1), subacute (Type 11) and chronic (Type 111)  . All the 16 patients reported here fall within the subacute type 11.
Treatment of gallbladder perforation can be conservative in the very critically ill  , with percutaneous needle aspiration  ; definitive treatment, however, is cholecystectomy as was done in all of the 16 patients herein reported. Complications of the disease include liver abscess  , retroperitoneal tumor  , and, of course, death as seen in three of the 16 patients reviewed here.
In conclusion, gallbladder perforation is an unusual but not an uncommon complication of cholecystitis (especially the acalculus type) and cholelithiasis (especially with multiple stones). Its diagnosis can be made preoperatively with a high degree of suspicion of the condition aided by ultrasonographic and cholescintigraphic findings and clinched with the finding of bilious fluid on paracentesis abdominis. Increased preoperative awareness and diagnosis of the condition will diminish morbidity and mortality rate of the disease.
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