GALL BLADDER PERFORATION MIMICKING ACUTE CHOLECYSTITIS
Jayashri S Pandya*, N K Desai**, J H Palep**
*Hon. Surgeon; **Resident; Department of General Surgery, BYL Nair Hospital and TN Medical College, Mumbai Central, Mumbai 400 008.
Perforation of gall bladder is a potential complication due to delay in diagnosis. A definitive diagnosis is uncommon before surgery. We report a case of 65 year old female who presented with acute cholecystitis, on surgery 24 hours later a sealed perforation of the gall bladder at the fundus was found.
Perforation of gall bladder is an increasingly recognized complication of acute cholecystitis. Despite the fact that early recognition and treatment decreased the mortality and morbidity, the disease continues to remain a diagnostic dilemma. The purpose of presenting this case is that perforated gall bladder mimicking as an acute cholecystitis should be kept in mind as one of the differentials. Clinical profiles have been developed for patients at risk of developing acute v/s chronic gall bladder perforations. Awareness of this is important for early recognition and treatment of gall bladder perforation.
A 65 year old female presented with a 5 day old history of nausea and pain in the right hypochondrium. Since one month, she had similar complaints. She had fever with chills and rigors since 20 days and widal was positive. Patient was started on antibiotics. The pain did not subside and clinical diagnosis of acute cholecystitis was made. She had a direct bilirubin of 9.2 with normal enzymes and alkaline phosphatase of 10.3. Within 8-10 hours, pain and tenderness in the right hypochondrium increased and sonography showed pericholecystic collection of 5.8 cm x 4.2 cm perforation of the gall bladder and with a suspicious radio-opaque density at the lower end of CBD. Around 15-20 ml of serosanguinous collection was tapped and the fluid was sent for microbiological examination. The fluid grew E-coli organisms. ERCP was performed, sphincterotomy with removal of duct calculi was done. A stent was inserted. The patient was taken up for surgery on view of the perforation of the gall bladder. There were adhesions around the gall bladder and omentum was stuck at the fundus, suggesting the site of perforation. The stent was palpated in the common bile duct. Post-operative recovery was uneventful. All investigations came back to baseline level within 7 days. Suture removal was done on day 8. Stent was removed after three weeks. The patient was asymptomatic at last follow-up.
Fig.1 : Ultrasonography of the abdomen : Left : Hypoechoic collection beneath the right lobe of liver, stomach and the transverse colon measuring 4.3 cm x 2.3 cm.
Right : Hypoechoic collection beneath the left lobe of liver, stomach and the transverse colon measuring 2.8 cm x 2.0 cm.
The reported mortality in elderly patients is quite high, being at least 9% in some series. Gall bladder perforations can be divided into 3 types.
Type I Bile stained peritonitis. Type II As a sub acute process with a pericholecystic abscess/collection. Type III a pericholecystic abscess/collection.
Our case falls into type II. It has been observed that chronic cholelithiasis is not necessary and essential feature of this complication. But the incidence of chronic cholecystitis by clinical history in cases of sub acute gall bladder perforation is about 35%.
Gall bladder has a dual blood supply. Hence, though acute cholecystitis is common, avascular necrosis and gangrene with perforation is relatively uncommon. In presence of generalized vascular insufficiency, localized tissue ischaemia leads to cellular dysfunction. The gall bladder fundus is most common site for perforation. It is interesting to note that patients with type II perforation presented with elevated levels of direct and total bilirubin. The transperitoneal reabsorption of bile spilled from perforation may contribute to hyper bilirubinaemia. Findings are less common in a non-perforated gall bladder. The radiological diagnosis has improved in the last 15 years with the advent of ultrasonography, computerized tomography, and biliary scintigraphy. In spite of these advances, it is very difficult to diagnose type II and type III perforation. Type I can be diagnosed as a free fluid in abdomen which is bilious on paracentesis. Pericholecystic collection with evidence of acute cholecystitis in an elderly patient should make one suspect sealed perforation. Thus, suspicion of perforation mandates aggressive resuscitation and early surgery. This helps in significantly reducing the morbidity and mortality.
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