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Table of Contents
CASE REPORTS
Year : 2022  |  Volume : 14  |  Issue : 1  |  Page : 33-35

Gall bladder perforation with contained bilioma: A rare complication of Calculous cholecystitis


1 Department of General Surgery, L.N. Medical College and J.K. Hospital, Bhopal, Madhya Pradesh, India
2 Department of Radiodiagnosis, L.N. Medical College and J.K. Hospital, Bhopal, Madhya Pradesh, India

Date of Submission20-Sep-2022
Date of Acceptance11-Apr-2022
Date of Web Publication21-Jul-2022

Correspondence Address:
Sakshi Goyal
Department of General Surgery, L.N. Medical College and J.K. Hospital, Bhopal, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njgh.njgh_25_20

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  Abstract 

Gall bladder perforation (GBP) is a rare and potentially life-threatening complication of acute cholecystitis. The main cause of GBP is cholecystitis with or without cholelithiasis and is often associated with high morbidity and mortality. It is subdivided into three categories, whereas the development of biloma is extremely rare. We report an interesting case of GBP after acute calculous cholecystitis causing subhepatic bilioma formation who presented in emergency with pain in the right upper abdomen and fever.

Keywords: Acute cholecystitis, bilioma, gallbladder perforation


How to cite this article:
Anand K, Goyal S, Tiwari A, Dave PK. Gall bladder perforation with contained bilioma: A rare complication of Calculous cholecystitis. Niger J Gastroenterol Hepatol 2022;14:33-5

How to cite this URL:
Anand K, Goyal S, Tiwari A, Dave PK. Gall bladder perforation with contained bilioma: A rare complication of Calculous cholecystitis. Niger J Gastroenterol Hepatol [serial online] 2022 [cited 2022 Aug 19];14:33-5. Available from: https://www.njghonweb.org/text.asp?2022/14/1/33/351552




  Introduction Top


Gall bladder perforation (GBP) is an uncommon complication of acute cholecystitis with an incidence rate of 0.8%–4.8% and a mortality rate of 9.5%–16%.[1],[2] GBP due to acalculous cholecystitis is more common than calculus cholecystitis. It has a male preponderance of above 60 years with systematic diseases[2],[3] The main cause of GBP is cholecystitis with or without cholelithiasis.[4] Usually, patients with GBP present with localized or diffuse peritonitis causing dilemma in early diagnosis. Radiological evaluations serve a vital role in early identification and appropriate intervention. The proposed mechanism of GBP is persistent inflammation and increased intracholecystic pressure due to impacted stone leading to ischemia, necrosis, and perforation.

The fundus, the most distant part from the main feeding artery, is the most common site for perforation. Classification of GBP was given by Niemeier: Type 1-(acute) free perforation into the peritoneal cavity, Type 2-(subacute)perforation with pericholecystic abscess, and Type 3-(chronic) perforation with cholecystoenteric fistula.[5] Type II is the most common type; whereas the development of bilioma is extremely rare.[6]

GBP is an uncommon complication of acute cholecystitis with an incidence rate of 0.8%–4.8% and a mortality rate of 9.5%–16%.[1],[2] GBP due to acalculus cholecystitis is more common than calculus cholecystitis. It has a male preponderance of above 60 years with systematic diseases[2],[3]The main cause of GBP is cholecystitis with or without cholelithiasis.[4] Usually, patients with GBP present with localized or diffuse peritonitis causing dilemma in early diagnosis. Radiological evaluations serve a vital role in early identification and appropriate intervention. The proposed mechanism of GBP is persistent inflammation and increased intracholecystic pressure due to impacted stone leading to ischemia, necrosis, and perforation.


  Case history Top


A 61-year-old man presented with pain in the right upper abdomen for 7 days and mild grade fever for 2 days; associated with abdominal distention and non-passage of flatus and faeces for 1 day. There was a positive history of Diabete mellitus, type II (DM-II) without any other comorbidity. On examination, distended abdomen, tenderness, and guarding in the right upper quadrant of abdomen were present with normal vitals.

Investigations revealed Hb 13.1 g%, Total Leucocyte count (TLC) 12200/cumm, total bilirubin 1.3 (direct 0.81), Aspartate transaminase(AST) 42U/L, Alanine transaminase (ALT) 57 U/L, and Alkaline phosphatase (ALP) 204 U/L; Prothrombin time/Intermational normalized ratio (PT/INR), amylase, and lipase were within normal limits. X-ray abdomen erect did not show any free gas under the right hemidiaphragm.

Ultrasonograghy of the abdomen showed distended GB with multiple echogenic foci and GB wall discontinuity causing anechoic collection in subhepatic region; rule out acute calculus cholecystitis with perforation with pericholecystic collection. Contrast-enhanced computed tomography (CECT) abdomen revealed dilated GB with impacted calculus in GB neck. Focal perforation in fundus was seen with pericholecystic and subhepatic collection (size 7.5 cm × 3.5 cm) [Figure 1] and [Figure 2].
Figure 1: Sagittal CT showing distended GB (arrowhead) with pericholecystic and subhepatic collection (arrows)

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Figure 2: Axial CT showing distended GB with impacted calculus in neck of GB

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  Intra operative findings Top


On the basis of the above findings, we decided to perform laparoscopic cholecystectomy where perihepatic pus collection with subhepatic bilioma formation was seen [Figure 3]. The procedure was converted to open cholecystectomy because the gall bladder could not be localized due to dense adhesions and distorted biliary anatomy. Adhered omentum was gently separated from inferior surface from liver and collections were drained. Evidence of grossly distended gall bladder was seen with adhered omentum in the fundic region suggesting perforation at that site. Cholecystectomy was performed and a subhepatic drain was placed. Postoperative period was uneventful. Grossly specimen showed a pin-hole-sized perforation at fundus [Figure 4] and HPE showed features of cholecystitis.
Figure 3: Subhepatic bilioma

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Figure 4: Pin-hole-sized perforation seen at fundus of GB

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  Discussion Top


GBP is one of the rare complications of acute cholecystitis. Conditions such as cholelithiasis, infections, malignancy, diabetes, atherosclerosis, steroid therapy, etc. are predisposing risk factors. It is difficult to discriminate clinically between the patients with perforated gallbladder and those with uncomplicated acute cholecystitis. As a result, the diagnosis is often delayed or even missed. Perforation at fundus is less likely to be covered by omentum, so gall stones and bile are more likely drain into peritoneal space causing diffuse peritonitis. But if the perforation occurs at the neck or the duct, it becomes sealed off by the omentum or the intestines causing localized peritonitis and pericholecystic fluid.[2],[7] However, in certain instances, a low-grade and chronic bile leakage from the gallbladder becomes encapsulated to form a biloma. Bilioma is defined as intra-or extra-hepatic bile collection outside the biliary tree with well-demarcated capsule in 1983 by Kuligowska et al.[8] In certain cases, spontaneous bilioma formation may occur due to bile duct disruption but rarely with GBP. CT scans and USG are useful in establishing the diagnosis by revealing a fluid collection. Without timely intervention, the collection may progress to an infected abscess, and become fatal.


  Conclusion Top


Formation of bilioma is extremely rare; though GBP is subdivided into three categories, formation of bilioma can be classified as another type. Extravasation of unconcentrated bile from a pinhole-sized perforation of gallbladder may result in insidious clinical presentation and an undetected leak site. This causes diagnostic dilemma and high morbidity and mortality.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kannan U, Parshad R, Regmi SK An unusual presentation of biloma five years following cholecystectomy: A case report. Cases J 2009;2:8048.  Back to cited text no. 1
    
2.
Derici H, Kara C, Bozdag AD, Nazli O, Tansug T, Akca E Diagnosis and treatment of gallbladder perforation. World J Gastroenterol 2006;12:7832-6.  Back to cited text no. 2
    
3.
Ong CL, Wong TH, Rauff A Acute gall bladder perforation: A dilemma in early diagnosis. Gut 1991;32:956-8.  Back to cited text no. 3
    
4.
Roslyn J, Busuttil RW Perforation of the gallbladder: A frequently mismanaged condition. Am J Surg 1979;137:307-12.  Back to cited text no. 4
    
5.
Niemeier OW Acute free perforation of the gall-bladder. Ann Surg 1934;99:922-4.  Back to cited text no. 5
    
6.
Seyal AR, Parekh K, Gonzalez-Guindalini FD, Nikolaidis P, Miller FH, Yaghmai V Cross-sectional imaging of perforated gallbladder. Abdom Imaging 2014;39:853-74.  Back to cited text no. 6
    
7.
Kim HJ, Park SJ, Lee SB, Lee JK, Jung HS, Choi CK, et al. A case of spontaneous gallbladder perforation. Korean J Intern Med 2004;19:128-31.  Back to cited text no. 7
    
8.
Kuligowska E, Schlesinger A, Miller KB, Lee VW, Grosso D Bilomas: A new approach to the diagnosis and treatment. Gastrointest Radiol 1983;8:237-43.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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Abstract
Introduction
Case history
Intra operative ...
Discussion
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