| Popis: |
Background Gallbladder perforation is a life-threatening event, a severe complication of acute cholecystitis. It is difficult to differentiate to uncomplicated acute cholecystitis. There are three types of gallbladder perforation; (I) acute free perforation into the peritoneal cavity; (II) subacute perforation with pericholecystic abscess; (III) chronic perforation with cholecystoenteric fistula. Type I and II mostly occurred in patients below 50-year-old, while type III in elderly patients with a long history of the biliary stone. We present a case of mixed type I and II gallbladder perforation in an asymptomatic patient. Methods A 63-years old female with no medical comorbidity was admitted due to watery stool, without nausea, vomiting, abdominal pain or fever. She had a 10-year history of mild epigastric discomfort. She was normotensive, slightly tachycardia and tachypneu with no fever. There was a mass in the right hypochondrium diametered 10 centimeters, tender on palpation, but no signs of general peritonitis. Alkaline phosphatase and gamma-glutamyl transferase levels were normal. The ultrasound found distended gallbladder with a thickened wall (figure 1A), gallstones diametered 0.6–1.2 centimeters within sludge (figure 1B) and an anechoic lesion with internal echo outside the liver (figure 1C). Results On laparotomy, there was dense adhesion between the margin of the right lobe of the liver with anterior peritoneum, and between the omentum with liver, gallbladder and transverse colon, and 500 milliliters of pus within adhesion. The gallbladder was distended with a perforation near fundus, and 8 gallstones were retrieved. Cholecystectomy was then performed. The patient was discharged on the 8th day post-surgery. The patient did not have symptoms and signs suggestive of gallbladder disease or perforation. Location of perforation was at the fundus (type I), but it was sealed by omentum and transverse colon. The sealing contained the bile leak within the extra peritoneal gallbladder fossa thus resulting pericholecystic abscess (type II). Ultrasound and CT scan findings in the setting of gallbladder perforation are pericholecystic fluid collections, gallbladder wall thickening and cholelithiasis. Conclusions High clinical suspicion of gallbladder perforation based on history, physical examination and ultrasound are sufficient to perform a surgical intervention. |
