Case Report
A Case of Gallbladder Perforation Detected by Sonography After a Blunt Abdominal Trauma Maiko Hongo, MD,1 Hideaki Ishida, MD, PhD,2 Hiroko Naganuma, MD, PhD,3 Hiroshi Yoshioka, MD, PhD,1 Takamitu Kasuya, MD, PhD,1 Makoto Niwa, MD, PhD1 1
Department of Surgery, Yokote Municipal Hospital, 5-31 Negishi-cho, Yokote-shi, Akita 013-8602, Japan Department of Gastroenterology, Akita Red Cross Hospital, 222-1 Kamikitade Saruta, Akita-shi, Akita 010-1495, Japan 3 Department of Gastroenterology, Yokote Municipal Hospital, 5-31 Negishi-cho, Yokote-shi, Akita 013-8602, Japan 2
Received 5 December 2012; accepted 10 September 2013
ABSTRACT: Gallbladder (GB) perforation is a very rare posttraumatic abdominal injury. It is potentially life-threatening, and good outcome requires early diagnosis. We present a case of isolated posttraumatic GB perforation in which the precise sonographic (US) diagnosis led us to apply proper management. Color Doppler US showed a clear toand-fro flow signal passing through the perforation site, and contrast-enhanced US confirmed the presence of a small defect in the GB wall. When examining posttraumatic patients, the possibility of GB perforation must be kept in mind. Color Doppler US and contrast-enhanced US are the examinations of choice to detect the perforation site and show bile C movement through the perforation. V 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42:301–304, 2014; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.22111 Keywords: gallbladder; perforation; Doppler; contrast-enhanced ultrasound; trauma
G
allbladder (GB) perforation is a very rare posttraumatic abdominal injury, which is rarely diagnosed before surgery. GB perforation is potentially life-threatening, and good outcome requires early diagnosis. We present a case of posttraumatic GB perforation diagnosed by sonography (US), which enabled us to establish prompt and appropriate treatment. To the best of our knowledge, this is the first report describing the usefulness of US in the diagnosis of posttraumatic GB perforation. Correspondence to: H. Naganuma The authors have no conflict of interest. C 2013 Wiley Periodicals, Inc. V
VOL. 42, NO. 5, JUNE 2014
CASE REPORT
An 80-year-old woman suffering from chronic cardiac failure was referred to our hospital with a complaint of progressive abdominal pain of 2 days’ duration after a fall. She had no significant personal or family medical history. On arrival, the patient reported severe rebound tenderness over the whole abdomen. Laboratory data on admission showed active inflammation with a white blood cell count of 9,000/ll, Creactive protein of 32.5 mg/dl, mild anemia (a red blood cell count 284 3 104/ll, and hemoglobin 10.3 g/dl), liver dysfunction (aspartate aminotransferase 78 IU/l, alanine aminotransferase 52 IU/l), and renal dysfunction (blood urea nitrogen 56.2 mg/dl, creatinine 1.9 mg/dl). Conventional US, which was performed using a EUB 8500 system (Hitachi-Aloka Medical, Tokyo, Japan) and a 2–5 MHz convex transducer, showed that the GB was not distended (56 3 40 mm), that its wall was thickened (8 mm), and that it contained a small amount of echogenic debris. US showed also pooling of a small amount of fluid around the GB fundus, and a small defect was noted in the fundus wall (Figure 1). Color Doppler US showed a clear toand-fro flow signal passing through the defect site (Figure 2). Contrast-enhanced US was performed under pulse inversion contrast specific mode and a mechanical index of 0.28. The contrast agent used was Sonazoid (Daiichi-Sankyo, Tokyo, Japan), which consists of a phospholipid shell containing perfluorocarbon microbubbles. Sonazoid was intravenously administered as a bolus (0.01 ml/kg), and we observed the lesion 301
HONGO ET AL DISCUSSION
FIGURE 1. Oblique sonogram shows pooling of fluid around the gallbladder fundus, and a small defect was noted in the fundus wall (arrow). G, gallbladder; F, fluid collection.
successfully during the first 2 minutes and then at 5 and 10 minutes after injection. After injection of Sonazoid, it confirmed the presence of a small defect by enhancing the GB wall (Figure 3). CT also showed fluid collection in the upper abdomen and the GB wall was discontinuous at the fundus, although the findings were less clearly demonstrated by CT than by US (Figure 4). The abdomen was otherwise normal on CT. Emergent laparoscopy was performed with the presumptive diagnosis of GB perforation, based on the combination of the laboratory data, physical examination, US, and CT finding. Laparoscopy found bilious fluid in the abdominal cavity and a small amount of bile run out through the perforated GB fundus (Figure 5). No other injuries were identified during laparoscopy. Laparoscopic cholecystectomy and drainage were performed. After surgery the patient’s cardiac function was slightly aggravated and retarded the patient’s postoperative recovery. After 2 weeks of medical treatment, her cardiac function was normalized and she was discharged on postoperative day 24 after her deteriorated cardiac function normalized.
Theoretically, abdominal trauma can cause injury to any abdominal organ. However, a literature review shows that the lesions are, in descending order of frequency, liver lacerations (27–33%), splenic lacerations (15–16%), paraduodenal or mesenteric hematomas (13–16%), pancreatic contusions (5–8%), and that the incidence of GB injury is very low at 2%.1,2 This relative low incidence is thought to be due to anatomic protection afforded by the ribs and cushioning of the liver situated anterior to the GB. Most posttraumatic GB injuries coexist with other associated intra-abdominal complications, including liver lacerations, duodenal perforations, and splenic lacerations and GB injury is usually found during laparotomy performed to treat other lesions.1,2 Isolated GB injury, as in the presented case, is considered to be rare, although the precise incidence remains unknown.3,4 The literature shows that compared with neck and body, the fundus is most vulnerable, as in our case, probably because it is not covered by the liver and is susceptible to abdominal trauma especially when GB is distended or is thin-walled.5–8 The presence of chronic changes associated with gallstones resulting in GB wall thickening, is considered to be a protecting factor against GB injury during abdominal trauma. When GB perforates, bile and blood extravasate into the abdominal cavity and can cause symptoms. A review of previously reported cases of posttraumatic GB perforations shows a wide range of symptoms, including abdominal distension, tenderness, fever, pain, leukocytosis, or anemia (alone or in combination). However, laboratory data and physical examination are usually vague, and patients may be symptomfree, leading to a delayed diagnosis. This fact emphasizes the importance of using complementary imaging modalities, especially US, because
FIGURE 2. Color Doppler sonogram shows a to-and-fro flow signal passing through the gallbladder wall. (A) Forward, (B) backward.
302
JOURNAL OF CLINICAL ULTRASOUND
GB PERFORATION
FIGURE 5. Laparoscopic view shows small amount of bile run out through the perforation of gallbladder fundus (arrow). A, abdominal wall; B, bilious fluid collection; G, gallbladder; L, liver. FIGURE 3. Contrast-enhanced US shows the small defect better by enhancing the gallbladder wall (arrow). G, gallbladder; F, fluid collection.
it is a first-line modality for examining posttraumatic patients. Introduction of tissue harmonic imaging, color Doppler US, and contrast-enhanced image has allowed more detailed evaluation of tissue damage and changes in vascularity, resulting in more accurate US assessment of GB disease. According to the literature, gray-scale US findings of GB perforation are nonspecific in the majority of cases, including pericholecystic fluid collection, thickened GB wall, collapsed GB, and intraluminal echogenic debris due to hematoma.5,6 However, the diagnosis can be easily made if US detects the perforation site in the GB wall or bile movement through the perforation.7 Thus, when suspecting GB perforation or when detecting the above-mentioned gray-scale findings in posttraumatic patients, color Dopp-
FIGURE 4. Contrast-enhanced CT scan shows fluid collection in the upper abdomen and the discontinuing in the gallbladder wall at the fundus (arrow). F, fluid collection. VOL. 42, NO. 5, JUNE 2014
ler US should be used. Recently, contrastenhanced US has been used for the diagnosis of abdominal tumors.8 When suspecting GB perforation, contrast-enhanced US is another effective option to make the final diagnosis. The treatment is usually cholecystectomy, as was performed in our case. In most cases with posttraumatic GB perforation, it is performed during the open procedure, which serves to confirm the absence of associated lesions.9,10 In conclusion, we have reported a case of posttraumatic isolated GB perforation in which the precise US diagnosis led us to perform an appropriate therapy. When examining posttraumatic patients, the possibility of GB perforation should be kept in mind. Color Doppler US and contrast-enhanced US can visualize clearly the perforation site and bile movement through the perforation site.
REFERENCES 1. Sonderstrom CA, Maekawa K, Dupriest RW, et al. Gallbladder injuries resulting from blunt abdominal trauma. An experience and review. Ann Surg 1981;193:60. 2. Sharma O. Blunt gallbladder injuries: presentation of twenty-two cases with review of the literature. J Trauma 1995;39:576. 3. Burgess P, Fulton RL. Gallbladder and extrahepatic biliary injury following abdominal trauma. Injury 1992;23:413. 4. Van Kercschaver O, De Witte B, Kint M, et al. An unusual case of blunt abdominal trauma: a bleeding and ruptured gallbladder managed by laparoscopy. Acta Chir Belg 2006;106:417. 5. Kao EY, Desser TS, Jeffrey RB. Sonographic diagnosis of traumatic gallbladder rupture. J Ultrasound Med 2002;21:1295. 6. Sood BP, Kaira N, Gupta S, et al. Role of sonography in the diagnosis of gallbladder perforation. J Clin Ultrasound 2002;30:270.
303
HONGO ET AL 7. Konno K, Ishida H, Sato M, et al. Gallbladder perforation: color Doppler findings. Abdom Imaging 2002;27:47. 8. Zechner PM, Rienmueller S, Dorrr K, Genger C, et al. Contrast-enhanced ultrasound detects gallbladder perforation in a patient with acute abdominal pain. Am J Emerg Med 2012;30: 516 e5.
304
9. Jaggard MK, Johal N, Haddad M, et al. Isolated gallbladder perforation following blunt abdominal trauma in a six-year-old child. Ann R Coll Surg Engl 2011;93:e29. 10. Jaggard MK, Johal N, Choudhry M. Blunt abdominal trauma resulting in gallbladder injury: a review with emphasis on pediatrics. J Trauma 2011;70:1005.
JOURNAL OF CLINICAL ULTRASOUND
A Case of Gallbladder Perforation Detected by Sonography After a Blunt Abdominal Trauma Maiko Hongo, MD,1 Hideaki Ishida, MD, PhD,2 Hiroko Naganuma, MD, PhD,3 Hiroshi Yoshioka, MD, PhD,1 Takamitu Kasuya, MD, PhD,1 Makoto Niwa, MD, PhD1 1
Department of Surgery, Yokote Municipal Hospital, 5-31 Negishi-cho, Yokote-shi, Akita 013-8602, Japan Department of Gastroenterology, Akita Red Cross Hospital, 222-1 Kamikitade Saruta, Akita-shi, Akita 010-1495, Japan 3 Department of Gastroenterology, Yokote Municipal Hospital, 5-31 Negishi-cho, Yokote-shi, Akita 013-8602, Japan 2
Received 5 December 2012; accepted 10 September 2013
ABSTRACT: Gallbladder (GB) perforation is a very rare posttraumatic abdominal injury. It is potentially life-threatening, and good outcome requires early diagnosis. We present a case of isolated posttraumatic GB perforation in which the precise sonographic (US) diagnosis led us to apply proper management. Color Doppler US showed a clear toand-fro flow signal passing through the perforation site, and contrast-enhanced US confirmed the presence of a small defect in the GB wall. When examining posttraumatic patients, the possibility of GB perforation must be kept in mind. Color Doppler US and contrast-enhanced US are the examinations of choice to detect the perforation site and show bile C movement through the perforation. V 2013 Wiley Periodicals, Inc. J Clin Ultrasound 42:301–304, 2014; Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jcu.22111 Keywords: gallbladder; perforation; Doppler; contrast-enhanced ultrasound; trauma
G
allbladder (GB) perforation is a very rare posttraumatic abdominal injury, which is rarely diagnosed before surgery. GB perforation is potentially life-threatening, and good outcome requires early diagnosis. We present a case of posttraumatic GB perforation diagnosed by sonography (US), which enabled us to establish prompt and appropriate treatment. To the best of our knowledge, this is the first report describing the usefulness of US in the diagnosis of posttraumatic GB perforation. Correspondence to: H. Naganuma The authors have no conflict of interest. C 2013 Wiley Periodicals, Inc. V
VOL. 42, NO. 5, JUNE 2014
CASE REPORT
An 80-year-old woman suffering from chronic cardiac failure was referred to our hospital with a complaint of progressive abdominal pain of 2 days’ duration after a fall. She had no significant personal or family medical history. On arrival, the patient reported severe rebound tenderness over the whole abdomen. Laboratory data on admission showed active inflammation with a white blood cell count of 9,000/ll, Creactive protein of 32.5 mg/dl, mild anemia (a red blood cell count 284 3 104/ll, and hemoglobin 10.3 g/dl), liver dysfunction (aspartate aminotransferase 78 IU/l, alanine aminotransferase 52 IU/l), and renal dysfunction (blood urea nitrogen 56.2 mg/dl, creatinine 1.9 mg/dl). Conventional US, which was performed using a EUB 8500 system (Hitachi-Aloka Medical, Tokyo, Japan) and a 2–5 MHz convex transducer, showed that the GB was not distended (56 3 40 mm), that its wall was thickened (8 mm), and that it contained a small amount of echogenic debris. US showed also pooling of a small amount of fluid around the GB fundus, and a small defect was noted in the fundus wall (Figure 1). Color Doppler US showed a clear toand-fro flow signal passing through the defect site (Figure 2). Contrast-enhanced US was performed under pulse inversion contrast specific mode and a mechanical index of 0.28. The contrast agent used was Sonazoid (Daiichi-Sankyo, Tokyo, Japan), which consists of a phospholipid shell containing perfluorocarbon microbubbles. Sonazoid was intravenously administered as a bolus (0.01 ml/kg), and we observed the lesion 301
HONGO ET AL DISCUSSION
FIGURE 1. Oblique sonogram shows pooling of fluid around the gallbladder fundus, and a small defect was noted in the fundus wall (arrow). G, gallbladder; F, fluid collection.
successfully during the first 2 minutes and then at 5 and 10 minutes after injection. After injection of Sonazoid, it confirmed the presence of a small defect by enhancing the GB wall (Figure 3). CT also showed fluid collection in the upper abdomen and the GB wall was discontinuous at the fundus, although the findings were less clearly demonstrated by CT than by US (Figure 4). The abdomen was otherwise normal on CT. Emergent laparoscopy was performed with the presumptive diagnosis of GB perforation, based on the combination of the laboratory data, physical examination, US, and CT finding. Laparoscopy found bilious fluid in the abdominal cavity and a small amount of bile run out through the perforated GB fundus (Figure 5). No other injuries were identified during laparoscopy. Laparoscopic cholecystectomy and drainage were performed. After surgery the patient’s cardiac function was slightly aggravated and retarded the patient’s postoperative recovery. After 2 weeks of medical treatment, her cardiac function was normalized and she was discharged on postoperative day 24 after her deteriorated cardiac function normalized.
Theoretically, abdominal trauma can cause injury to any abdominal organ. However, a literature review shows that the lesions are, in descending order of frequency, liver lacerations (27–33%), splenic lacerations (15–16%), paraduodenal or mesenteric hematomas (13–16%), pancreatic contusions (5–8%), and that the incidence of GB injury is very low at 2%.1,2 This relative low incidence is thought to be due to anatomic protection afforded by the ribs and cushioning of the liver situated anterior to the GB. Most posttraumatic GB injuries coexist with other associated intra-abdominal complications, including liver lacerations, duodenal perforations, and splenic lacerations and GB injury is usually found during laparotomy performed to treat other lesions.1,2 Isolated GB injury, as in the presented case, is considered to be rare, although the precise incidence remains unknown.3,4 The literature shows that compared with neck and body, the fundus is most vulnerable, as in our case, probably because it is not covered by the liver and is susceptible to abdominal trauma especially when GB is distended or is thin-walled.5–8 The presence of chronic changes associated with gallstones resulting in GB wall thickening, is considered to be a protecting factor against GB injury during abdominal trauma. When GB perforates, bile and blood extravasate into the abdominal cavity and can cause symptoms. A review of previously reported cases of posttraumatic GB perforations shows a wide range of symptoms, including abdominal distension, tenderness, fever, pain, leukocytosis, or anemia (alone or in combination). However, laboratory data and physical examination are usually vague, and patients may be symptomfree, leading to a delayed diagnosis. This fact emphasizes the importance of using complementary imaging modalities, especially US, because
FIGURE 2. Color Doppler sonogram shows a to-and-fro flow signal passing through the gallbladder wall. (A) Forward, (B) backward.
302
JOURNAL OF CLINICAL ULTRASOUND
GB PERFORATION
FIGURE 5. Laparoscopic view shows small amount of bile run out through the perforation of gallbladder fundus (arrow). A, abdominal wall; B, bilious fluid collection; G, gallbladder; L, liver. FIGURE 3. Contrast-enhanced US shows the small defect better by enhancing the gallbladder wall (arrow). G, gallbladder; F, fluid collection.
it is a first-line modality for examining posttraumatic patients. Introduction of tissue harmonic imaging, color Doppler US, and contrast-enhanced image has allowed more detailed evaluation of tissue damage and changes in vascularity, resulting in more accurate US assessment of GB disease. According to the literature, gray-scale US findings of GB perforation are nonspecific in the majority of cases, including pericholecystic fluid collection, thickened GB wall, collapsed GB, and intraluminal echogenic debris due to hematoma.5,6 However, the diagnosis can be easily made if US detects the perforation site in the GB wall or bile movement through the perforation.7 Thus, when suspecting GB perforation or when detecting the above-mentioned gray-scale findings in posttraumatic patients, color Dopp-
FIGURE 4. Contrast-enhanced CT scan shows fluid collection in the upper abdomen and the discontinuing in the gallbladder wall at the fundus (arrow). F, fluid collection. VOL. 42, NO. 5, JUNE 2014
ler US should be used. Recently, contrastenhanced US has been used for the diagnosis of abdominal tumors.8 When suspecting GB perforation, contrast-enhanced US is another effective option to make the final diagnosis. The treatment is usually cholecystectomy, as was performed in our case. In most cases with posttraumatic GB perforation, it is performed during the open procedure, which serves to confirm the absence of associated lesions.9,10 In conclusion, we have reported a case of posttraumatic isolated GB perforation in which the precise US diagnosis led us to perform an appropriate therapy. When examining posttraumatic patients, the possibility of GB perforation should be kept in mind. Color Doppler US and contrast-enhanced US can visualize clearly the perforation site and bile movement through the perforation site.
REFERENCES 1. Sonderstrom CA, Maekawa K, Dupriest RW, et al. Gallbladder injuries resulting from blunt abdominal trauma. An experience and review. Ann Surg 1981;193:60. 2. Sharma O. Blunt gallbladder injuries: presentation of twenty-two cases with review of the literature. J Trauma 1995;39:576. 3. Burgess P, Fulton RL. Gallbladder and extrahepatic biliary injury following abdominal trauma. Injury 1992;23:413. 4. Van Kercschaver O, De Witte B, Kint M, et al. An unusual case of blunt abdominal trauma: a bleeding and ruptured gallbladder managed by laparoscopy. Acta Chir Belg 2006;106:417. 5. Kao EY, Desser TS, Jeffrey RB. Sonographic diagnosis of traumatic gallbladder rupture. J Ultrasound Med 2002;21:1295. 6. Sood BP, Kaira N, Gupta S, et al. Role of sonography in the diagnosis of gallbladder perforation. J Clin Ultrasound 2002;30:270.
303
HONGO ET AL 7. Konno K, Ishida H, Sato M, et al. Gallbladder perforation: color Doppler findings. Abdom Imaging 2002;27:47. 8. Zechner PM, Rienmueller S, Dorrr K, Genger C, et al. Contrast-enhanced ultrasound detects gallbladder perforation in a patient with acute abdominal pain. Am J Emerg Med 2012;30: 516 e5.
304
9. Jaggard MK, Johal N, Haddad M, et al. Isolated gallbladder perforation following blunt abdominal trauma in a six-year-old child. Ann R Coll Surg Engl 2011;93:e29. 10. Jaggard MK, Johal N, Choudhry M. Blunt abdominal trauma resulting in gallbladder injury: a review with emphasis on pediatrics. J Trauma 2011;70:1005.
JOURNAL OF CLINICAL ULTRASOUND
