PICTURES IN DIGESTIVE PATHOLOGY

 

Gallbladder perforation after closed thoracoabdominal trauma, diagnosed and treated by ERCP

Perforación vesicular tras traumatismo toracoabdominal cerrado diagnosticado y tratado mediante CPRE

 

 

David Ruiz-Clavijo, María Rullan, Marian Casi and Jesús Urman

Complejo Hospitalario de Navarra. Pamplona, Navarra. Spain

 

 

Introduction

Single gallbladder injury after abdominal trauma is a rare finding. Early diagnosis of this disease is often difficult due to the variability of symptoms and unspecific results in common radiological tests. The usual management in patients with vesical trauma is surgery.

We report a case of a patient with a gallbladder perforation after closed thoracoabdominal trauma diagnosed and treated with ERCP and a conservative management, with good clinical evolution.

 

Case report

A 55-year-old male with a past history of thoracoabdominal trauma presented with dull and diffuse abdominal pain without signs of peritonitis and hemodynamic stability. Ascites were observed in the initial emergency ultrasound.

During the first 48 hours the patient presented an increase in ascites and fever. Analytical data highlights: hemoglobin, 10 mg/dl; GGT, 104 U/l, and CRP, 266 mg/dl. An abdominal computed tomography (CT) was requested (Fig. 1) and piperacillin/tazobactam treatment was initiated. Paracentesis of five liters was performed (RBCs: 21,000/mm³, 2,880 leukocytes/mm³, total bilirubin: 19.26 mg/dl, bile acids: 3,952.4 µmol/l).

 

 

Endoscopic retrograde cholangiopancreatography (ERCP) was performed due to a suspected bile leak, and a gallbladder leak was noted (Fig. 2). It was treated by sphincterotomy and the establishment of a 10 Fr biliary plastic stent for eight weeks (Fig. 3) with good results.

 

 

 

Discussion

The extrahepatic bile duct injury occurs mainly by iatrogenesis in laparoscopic surgery. Traumatic etiology is rare, the gallbladder break being an exceptional occurrence (1). Gallbladder injury may be classified as contusion, perforation, avulsion and traumatic cholecystitis. Concomitant abdominal injuries are usually found (liver, spleen and duodenal). Clinical presentation can be immediate (shock and peritonitis) or insidious, when the only injury is the bile leakage (2). CT findings are usually nonspecific and the usual treatment is cholecystectomy. In bile leakage situations, the approach was usually surgical; however, advances in ERCP and cholangio-RM have resulted in an improved diagnosis and the introduction of non-operative management in most patients (2).

In an incomplete bile duct injury, the European Society of Gastrointestinal Endoscopy (ESGE) recommends the performance of an ERCP with plastic stent insertion and removal in 4-8 weeks, with a success rate of 80-90% (3).

 

References

1. Zago TM, Pereira BMT, Calderan TRA, et al. Extrahepatic duct injury in blunt trauma: Two case reports and a literature review. Indian J Surg 2014;76(4):303-7. DOI: 10.1007/s12262-013-0885-5.         [ Links ]

2. Melamud K, Lebedis CA, Anderson SW, et al. Biliary imaging: Multimodality approach to imaging of biliary injuries and their complications. Radiographics 2014;34(3):613-23. DOI: 10.1148/rg.343130011.         [ Links ]

3. Pioche M, Ponchon T. Management of bile duct leaks. J Visc Surg Elsevier Masson SAS 2013;150(Suppl. 3):S33-8. DOI: 10.1016/j.jviscsurg.2013.05.004.         [ Links ]