PICTURES IN DIGESTIVE PATHOLOGY

 

Perforation of the gallbladder with communicating pericholecystic abscess: ultrasonographic diagnosis

Perforación de la vesícula biliar con absceso perivesicular comunicante: diagnóstico por ecografía

 

 

P. Grande-Pérez, J. Justo Pereira and F. Ramos

Serviço de Radiologia. Hospital Central de Faro. Portugal

 

Case report

A 75-year-old male patient with recurrent biliary colics attends the emergency service because of right upper-quadrant abdominal pain and fever for two days. The patient experiences pain when palpated on the right hypochondrium, with Murphy's sign and a temperature of 38 ºC.

Laboratory studies revealed leukocytosis with neutrophilia (15,000 leukocytes/mm³, 80% neutrophils) with hepatic enzymes and normal pancreatic amylase.

An initial ultrasound exam was performed, which showed evidence of acute cholecystitis with distended gallbladder, cholelithiasis, sludge, and diffuse thickening of the gallbladder wall (Fig. 1). Adjacent to the gallbladder a heterogeneous collection compatible with an abscess was seen, which communicated with the gallbladder through a break on the wall that was interpreted as a gallbladder perforation with communicating pericholecystic abscess (Fig. 2).

 

 

Abdominal contrast-enhanced CT confirmed the pericholecystic abscess, the thickening of the gallbladder wall, and an infundibular gallstone. A dilation of the distal common bile duct could also be seen.

The perforation of the gallbladder wall was not demonstrated by means of this procedure (Fig. 3).

 

The patient, waiting for elective surgery, was treated with antibiotics, which improved the patient's clinical condition.

 

Discussion

Perforation of the gallbladder wall is an infrequent complication of acute cholecystitis, but it is associated with a high mortality rate without early treatment (1). Three types of perforation (2) have been described, with the subacute form with pericholecystic abscess being most frequently observed (3,4). The clinical diagnosis of gallbladder perforation is usually difficult since symptoms can be undistinguishable from non-complicated acute cholecystitis. Although on most occasions the diagnosis of perforation using images is presupposed from indirect data like the presence of pericholecystic collections, an accurate diagnosis is possible with at least one of these three signs:

-Direct observation of the perforation or "hole sign".

-Communication between the abscess and gallbladder lumen through a gap in the gallbladder wall.

-Observation of gallstones in the pericholecystic collection (4).

Few cases have been published in which a communication between the pericholecystic abscess and the gallbladder is demonstrated by means of ultrasound scans (3). While we could not confirm these findings with CT, the great majority of published papers indicate that CT (1,4,5), and recently MRI, are more sensitive than ultrasounds for the diagnosis of gallbladder perforation.

 

References

1. Ergul E, Gozetlik EO. Perforation of gallbladder. Bratisl Lek Listy 2008; 109(5): 210-4.        [ Links ]

2. Niemeier OW. Acute free perforation of the gallbladder. Ann Surg 1934; 99: 922-4.        [ Links ]

3. Takada T, Yasuda H, Uchiyama K, Hasegawa H, Asagoe T, Shikata J. Pericholecystic abscess: classification of US findings to determine the proper therapy. Radiology 1989; 172: 693-7.        [ Links ]

4. Chun-Hsiung C, Tai-Youeng C, Huny-Ben P, Jer-Shyung H, Tsung-Lung Y, Chien-Fang Y. Computed tomography scanning for diagnosing gallbladder rupture: experience with 64 cases. Chin J Radiol 2000; 25(1): 13-6.        [ Links ]

5. Kim PN, Lee KS, Kim IY, Bae WK, Lee BH. Gallbladder perforation: comparison of US findings with CT. Abdom Imaging 1994; 19(3): 239-42.        [ Links ]