|Year : 2013 | Volume
| Issue : 3 | Page : 235-237
Spontaneous gall bladder perforation masquerading as a large abdominal lump: An uncommon presentation of a common entity
Kapil Jain, Suhani, Shadan Ali, Lalit Aggarwal, Shaji Thomas
Department of General Surgery, Lady Hardinge Medical College and Smt. Sucheta Kriplani Hospital, New Delhi, India
|Date of Web Publication||28-Mar-2014|
B-27, Vishwa apartment, Sector-9, Rohini, Delhi-110085
Source of Support: None, Conflict of Interest: None
Gall bladder perforation (GBP) is an uncommon complication of acute cholecystitis. Usually patients with GBP present with localized or diffuse peritonitis defending on their ability to localise the site of perforation. We recently cared for a 65-year-old female with GBP who presented to us with a painful large anterior abdominal lump and jaundice. On investigations, a large subcapsular liver collection was identified along with a perforation at the fundus of gall bladder and a calculus at the lower end of the common bile duct (CBD). The patient underwent pigtail catheter drainage of the collection under ultrasound guidance, endoscopic retrograde cholangiopancreatography, and papillotomy for CBD stone retrieval, followed by elective laparoscopic cholecystectomy with uneventful recovery. This case report highlights the fact that in a patient with gall stone disease presenting with a painful abdominal lump, the possibility of underlying GBP should be considered and the treatment should be individualised based on clinical condition of the patient.
Keywords: GBP, cholelithiasis, subcapsular collection
|How to cite this article:|
Jain K, Suhani, Ali S, Aggarwal L, Thomas S. Spontaneous gall bladder perforation masquerading as a large abdominal lump: An uncommon presentation of a common entity. Arch Int Surg 2013;3:235-7
|How to cite this URL:|
Jain K, Suhani, Ali S, Aggarwal L, Thomas S. Spontaneous gall bladder perforation masquerading as a large abdominal lump: An uncommon presentation of a common entity. Arch Int Surg [serial online] 2013 [cited 2019 Aug 24];3:235-7. Available from: http://www.archintsurg.org/text.asp?2013/3/3/235/129573
| Introduction|| |
Gallbladder stone disease is a common disease entity with a prevalence rate of 6%-12% in Northern India  and a worldwide incidence of 6%-20%.  Gall stones can lead to various complications including acute cholecystitis, choledocholithiasis, pancreatitis, gall bladder perforation (GBP), and empyema of the gall bladder. Among all of the complications, GBP is considered as a life-threatening complication of acute cholecystitis occurring in 2%-11% of the patients, , usually over 60 years of age.  Presentation of a patient with GBP varies depending upon the type of perforation. However, usually they present with localized or diffuse peritonitis. In this paper, we present a recently treated patient with spontaneous GBP who presented with a large abdominal lump.
| Case Report|| |
A 72-year-old female with history of biliary colic presented with 7 days history of painful abdominal swelling with jaundice, for which she was taking oral medications at home, the nature of which were not known to her. She had tachycardia, tachypnea, mild dehydration, and icterus. Abdominal examination revealed a large abdominal lump in the right hypochondrium, right lumbar, right iliac fossa, epigastrium, and umbilical region with size of about 20 × 15 cm [Figure 1]. The lump was tender with smooth surface, firm in consistency, and well-defined medial and inferior margins. Hematological investigations revealed total leukocyte count of 20800 cells/mm 3 , raised blood urea of 88 mg/dL, hyperbilirubinemia (total 4.1mg/dL, direct 3 mg/dL) and raised alkaline phosphatase of 247 U/L. Ultrasongraphy of abdomen depicted a large subcapsular collection indenting the anterior surface of the liver. Gall bladder area was poorly visualized with dilated common bile duct (CBD) of 12mm and intrahepatic biliary radicals dilatation. Contrast-enhanced computed tomography of the abdomen showed a large hepatic subcapsular collection with minimal fluid in the Morrison's pouch. There was a dilatation of the CBD with prominent intrahepatic biliary radicles. A breach in the wall of gall bladder was seen, which was shrunken [Figure 2]. A provisional diagnosis of GBP with subcapsular bilioma formation was made and under ultrasound (US) guidance the collection was drained with a pigtail catheter. About 3.2 L of infected bile was drained. The patient was started on antibiotics and she improved symptomatically with improved satiety, resolution of tachypnoea and normalisation of total leucocyte count in 2 days. Also the drain fluid became clear bile and the output decreased to around 2 L in the following 5 days. However, in view of persisting bilious output in the drain, dilated CBD and raised serum alkaline phosphatase, the patient underwent MRCP, which showed dilated CBD with calculus at the lower end [Figure 3]. The patient had ERCP in which the GBP was clearly delineated by contrast leak from the fundus. The impacted CBD stone was retrieved after doing needle knife papillotomy and CBD stent placed. After 6 weeks, the patient underwent an elective laparoscopic cholecystectomy. Intraoperatively, there were adhesions between the gall bladder fundus and omentum. The liver and other abdominal viscera were normal. The patient had an uneventful postoperative recovery. CBD stent was removed thereafter. The histopathological report of the gall bladder showed features of chronic cholecystitis.
|Figure 1: Clinical picture of the patient showing a large abdominal lump visible on inspection|
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|Figure 2: Contrast-enhanced computed tomography abdomen showing a large subcapsular liver collection|
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|Figure 3: MRCP showing intrahepatic biliary radicals, dilated common bile duct with choledocholithiasis, and well-defined renal cyst (hyperintense oval shadow)|
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| Discussion|| |
Acute uncomplicated calculus cholecystitis is more common among females with a female to male ratio of 2:1.  However, GBP is more frequent in males. , In acute cholecystitis, inflammation may progress and cause ischemia and necrosis resulting in GBP, occurring in 2%-11% of the patients. The fundus of the gall bladder is the most common site of perforation as it is the most peripheral part with regard to the blood supply.  Ischemia and necrosis were the probable cause of GBP in our patient. Perforation results from occlusion of the cystic duct (most often by a calculus) which causes a rise of intraluminal pressure. Increased intraluminal pressure in turn impedes venous and lymphatic drainage causing vascular compromise and therefore leads to necrosis and ultimate perforation of gallbladder.  Infections, malignancy, trauma, drugs (e.g., corticosteroids), and systemic diseases such as diabetes mellitus and atherosclerotic heart disease are predisposing factors.  In our case, cholecystitis with obstructed biliary system due to choledocolithiasis seems to be the most probable etiology leading to raised intraluminal pressure within the gall bladder and perforation.
The classification of GBP was given by Niemeier in 1934,  with type 1 or acute GBP being free gallbladder perforation and generalized biliary peritonitis, type 2 or subacute GBP as pericholecystic abscess and localized peritonitis, and type 3 or chronic GBP as cholecystoenteric fistula. Roslyn et al.,  reported that type 1 and 2 GBP tend to occur in younger patients, especially around the age of 50 years, whereas type 3 gallbladder perforations are more common in the elderly. Our case of GBP presenting with a large subcapsular bilioma is an unusual presentation not completely fitting into the above classification.
Patients with type 1 gallbladder perforation usually present with signs of peritoneal irritation such as extensive abdominal tenderness, guarding, and rebound tenderness. Patients with type 2 gallbladder perforation have localized signs and symptoms to the right upper abdomen. On the contrary, type 3 gallbladder perforations most often occur in patients with a previous long time history of gall stones. 
Cholecystectomy, drainage of abscess if present, and abdominal lavage are usually sufficient to treat gallbladder perforation. , Cholecystectomy can be performed after the infection is relived by US-guided percutaneus drainage in type 2 gallbladder perforations. Since the difficulties in diagnosis cause delay in treatment, higher morbidity and mortality rates are often encountered.  Glenn and Moore  have reported that the mortality rate of gallbladder perforation is 42%, while other studies reported that the mortality rates are decreased to 12%-16% owing to the developments in anesthesiology and intensive care conditions. 
The timing of surgery depends on the clinical scenario with early, emergency surgery being preferred in patients with diffuse peritonitis and those patients in whom there is no improvement on expectant treatment. In our case, there were no signs of peritonitis; hence, the patient underwent US-guided drainage of sub capsular collection by pigtail catheter and ERCP for CBD clearance and stenting. Once the hematological parameters and renal functions normalised and the pigtail catheter output decreased after CBD stenting, the pigtail catheter was removed. With the CBD stent in situ, the patient underwent elective laparoscopic cholecystectomy which was uneventful.
| Conclusion|| |
In patients with cholelithiasis, who present with a painful abdominal lump, the possibility of an underlying GBP should be considered. Because of varied presentation of GBP, the treatment should be individualized based on clinical condition of the patient.
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[Figure 1], [Figure 2], [Figure 3]