Review Article
European Journal of Trauma and Emergency Surgery
Isolated Gallbladder Injury after Blunt Abdominal Trauma: a Case Report and Review Tudyka Vera1, Toebosch Susan2, Zuidema Wietse3
Abstract We describe a case of isolated gallbladder contusion after deceleration trauma. On admission, no evident signs of intra-abdominal injury were present. However, after 24 h observation an explorative laparotomy was performed because of persistent abdominal complaints. A contusion of the gallbladder wall was found with intraluminal haematoma and a cholecystectomy was performed. Isolated injury of the gallbladder after blunt trauma is extremely rare. Risk factors are distention of the gallbladder, deceleration trauma and the presence of a relatively mobile gallbladder. Clinical signs often are very subtle. Delayed presentation is common with signs of hemobilia or obstruction due to intraluminal clots. Ultrasound and computed tomography are suitable diagnostic tools. However, the diagnosis is often missed if no other injuries are present. Signs pointing to gallbladder injury are a collapsed gallbladder with pericholecystic fluid or a hydroptic gallbladder with intraluminal hematoma. Hepatobiliary scintigraphy or angiography might be necessary if additional injuries are suspected. The choice of treatment depends on the kind of injury. Contusion of the gallbladder allows conservative treatment, but in case of a rupture, surgery will be necessary. Accompanying bile duct injuries can be treated by endoscopic stenting. If active arterial bleeding is present, selective embolization can be performed.
Key Words Gallbladder contusion Æ Abdominal trauma Æ Hemobilia Eur J Trauma Emerg Surg 2007;33:545–9 DOI 10.1007/s00068-007-6202-x
Case Report A 41-year-old homeless man was brought to the Emergency Department after falling from a height of 6 m. History taking was unreliable because of the patient being intoxicated by alcohol. Therefore the exact mechanism of the accident remained unclear. The patient complained of upper abdominal pain. Past medical history revealed addiction to illicit drugs, seropositivity for human immunodeficiency virus and a negative explorative laparotomy for a gun shot injury 15 years ago. Medications consisted of methadone, anti-retroviral drugs and an H2-blocker. On physical examination we found an agitated man with normal vital signs and a maximal Glasgow Coma Score of 15. There was upper right abdominal tenderness on palpation, but no rebound or guarding. The remainder of the physical examination was unremarkable. A chest X-ray revealed no abnormalities. A bedside ultrasound was performed and revealed no intra-abdominal fluid collections or other signs of injury to the liver, spleen, kidneys or aorta.
1
Department of Surgery, Maasland Ziekenhuis Sittard, Walramstraat 23, Sittard, 6131 BK, The Netherlands, 2 Department of Gastroenterology, University Hospital Maastricht, Maastricht, The Netherlands, 3 Department of Surgery, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands. Received: November 21, 2006; revision accepted: May 15, 2007; Published Online: July 23, 2007
Eur J Trauma Emerg Surg 2007 Æ No. 5 Ó URBAN & VOGEL
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Vera T, et al. Isolated Gallbladder Injury after Blunt Abdominal Trauma
Figure 1. Hydroptic gallbladder with intraluminal hematoma.
The pancreas could not be visualized by ultrasound. Laboratory findings revealed a previously known macrocytic anemia (Hb 11.1 g/dl, MCV 133); urinalysis was negative for erythrocytes. Because of the kind of trauma and his abdominal pain, the patient was admitted to the Observation Ward. The following day the abdominal pain persisted; physical examination did not reveal any new findings. The hemoglobin had decreased to 10.2 g/dl. Computed tomography (CT) of the abdomen was performed and showed a Hydroptic gallbladder with intraluminal fluid, possibly due to hematoma (Figure 1); the common bile duct appeared to be widened. The gallbladder wall was not thickened. Liver, kidneys, pancreas and duodenum were normal. There was a small amount of fluid seen pericholecystic as well as in the right paracolic fossa. Subsequently the patient underwent explorative laparotomy to rule out gallbladder perforation. A nonperforated, macroscopically normal gallbladder was found. Further exploration of the abdomen revealed no other injuries. A cholecystectomy was performed and after opening the removed gal bladder a large intraluminal haematoma was seen. Pathologic findings confirmed the diagnosis of hemobilia due to contusion of the gallbladder wall without any signs of perforation or laceration. Postoperatively the patient recovered without any complications and was able to be discharged 5 days after surgery.
546
Review of the Literature Epidemiology Injury of the gallbladder after blunt trauma is rare. Most cases occur following penetrating trauma [1]. Isolated blunt injury of the gallbladder is practically unknown. Searching relevant English literature, we only found five reports describing isolated gallbladder contusion [2–6]. In general, in 1–3% of patients undergoing laparotomy for blunt trauma, injury to the gallbladder is found [7–9]. This low prevalence may be due to the anatomical position of the gallbladder, being protected by the rib cage and embedded in the right lobe of the liver. This explains the high incidence of other intraabdominal injuries if gallbladder injury is present. Especially injury to the liver including intra- and extrahepatic bile ducts, spleen and duodenum is found [7–9]. As a consequence, morbidity and mortality of gallbladder trauma will be highly determined by complications of the accompanying injuries. There are, however, complications occurring especially after gallbladder injury. Hematoma of the gallbladder wall can result in local ischaemia leading to necrosis and perforation or so-called ‘‘delayed rupture’’ [8, 10]. Obstructing blood clots can induce a hydroptic cholecystitis, referred to as traumatic cholecystitis [5]. Both conditions will make cholecystectomy necessary. There seem to be some factors that increase the risk for injury of the gallbladder. Distention of the gallbladder as a result of alcohol ingestion or fasting, leads to a greater vulnerability of the gallbladder for injury [2, 3, 8, 11]. In addition intoxication by alcohol may lead to relaxation of the abdominal wall, which normally offers a certain degree of protection to trauma [12]. The type of trauma, especially blunt trauma due to acute deceleration, is also thought to increase the risk of gallbladder trauma. Acute deceleration may lead to compression of the gallbladder against the spine [8]. Also, tearing of a relatively mobile gallbladder and the extrahepatic ducts can occur [3, 9]. Our case report is an example of such a trauma mechanism, describing an acute deceleration due to a fall from 6 m height. Clinical Presentation The clinical presentation of contusion of the gallbladder highly depends on the symptoms of accompanying injury to other organs. If, as in our case, no accompanying injury occurred, symptoms can be subtle and limited to slight pain in the upper (right) abdomen. If there is accompanying hepatic injury, hemobilia might be one of
Eur J Trauma Emerg Surg 2007 Æ No. 5 Ó URBAN & VOGEL
Vera T, et al. Isolated Gallbladder Injury after Blunt Abdominal Trauma
the presenting symptoms. Hemobilia is described as (traumatic) haemorrhage into the biliary tract, commonly as a result of trauma to the liver. Depending on the amount of blood loss hemobilia may present as a classic upper gastrointestinal bleeding with melaena. In 0.2–3% of blunt hepatic injury hemobilia is present [13]. However, the same happens in case of intraluminal bleeding of the gallbladder wall because of laceration or contusion [14]. This type of upper gastrointestinal bleeding is often detected not before weeks or even months after the initial injury [14–16]. In very rare cases, hemobilia leads to obstruction caused by intrabiliary clots resulting in colic pain and/or jaundice [13, 15]. As bile works as a fibrinolytic agent, most intraductal blood clots will be dissolved and will pass the sphincter of Oddi without causing obstructive signs [15]. Diagnostics As mentioned before, the clinical presentation of isolated gallbladder trauma can be non-specific, allowing conservative management without the need of an aggressive diagnostic approach. In case of accompanying intra-abdominal injury more often sophisticated diagnostic imaging or even surgery will be needed to reveal gallbladder injury in an early stage. In the review by Burgess et al. [3], describing 24 cases of traumatic hemobilia who underwent surgery, the difficulty in diagnosing biliary tract or gallbladder injury is clearly demonstrated. None of the patients were preoperatively diagnosed with gallbladder and/or bile duct injury. Diagnostic peritoneal lavage has not been proven to be useful in detecting gallbladder injury [8]. Even in the presence of bile leakage a high incidence of negative lavages for bile was found [7, 12]. Still in case of a bile stained lavage, differentiation between gallbladder, liver or duodenal injury is not possible. To recognize biliary and gallbladder injuries on imaging, appropriate diagnostic tools and clinical experience are essential. Ultrasound and CT are suitable to detect gallbladder injuries. A collapsed gallbladder with pericholecystic fluid might represent perforation, while a hydroptic gallbladder with an inhomogenic fluid mass intraluminally is suggestive for intraluminal clots [9, 15, 17–19]. If bile demonstrates a high density on CT, hemobilia is strongly suspected. Other causes of highdensity bile should be excluded. Gallstones may present with the same characteristics as intraluminal clots, demonstrating a mobile entity on ultrasound and a high-density configuration on CT [14, 20]. At the same time, differentiating between a haematoma and gallbladder carcinoma can be a challenge as well. Especially in those cases where a previous abdominal
Eur J Trauma Emerg Surg 2007 Æ No. 5 Ó URBAN & VOGEL
trauma happened weeks before presentation, there might be doubts about any association between trauma and the findings on imaging. Surgery might be the only way to get the correct diagnosis [20]. If active bleeding is suspected or melaena is present, an abdominal CT should be performed. One should realize that in case of very subtle clinical signs, especially in case of delayed presentation, melaena might be the only sign pointing to biliary or gallbladder injury [14–16]. On CT intravascular contrast will be extravasal at the site of the lesion. Selective angiography offers the advantage of the possibility to treat active haemorrhage directly by performing embolization [9, 13, 16, 18]. Bile duct injuries can be found either with CT or magnetic resonance imaging (MRI), showing liver lacerations, ascites, or perihepatic fluid collections [14]. However, hepatobiliary scintigraphy has proven to be reliable in finding bile duct injury by showing leakage of bile at the site of disruption [9, 16, 21]. Endoscopic retrograde cholangiography (ERCP) might not be the first choice as diagnostic tool, as the presence of certain conditions like duodenal perforation should be ruled out before. However, ERCP can play a major role in treatment of traumatic bile duct injuries and/or hemobilia. In our case ultrasound was performed at the Emergency Department to rule out serious intraabdominal injury. A CT scan was made following an observational period because of clinical deterioration. Nowadays, CT is often preferred over ultrasound in the haemodynamically stable patient. This offers a more detailed anatomical view of the intra-abdominal organs and is less dependent on the skills and experience of the operator. However, this requires full availability of this diagnostic tool for emergency patients without any delay. Otherwise ultrasound remains a very useful tool to detect free intra-abdominal fluids as an indirect sign of intra-abdominal injury. If biliary or gallbladder injury is suspected, additional imaging should be performed as discussed above. Management Treatment of isolated blunt gallbladder injury allows conservative management, as long as the patient is haemodynamically stable, no melaena is present and abdominal pain is under control. One could assume a lot of cases of minimal gallbladder injury remain undiagnosed and heal without complications what justifies expectant observation [8]. However, as soon as any deterioration occurs, the initial approach must be revised. Additional imaging or even surgical exploration must be considered. In our case, because of a
547
Vera T, et al. Isolated Gallbladder Injury after Blunt Abdominal Trauma
decreased haemoglobin, an abdominal CT was performed which was highly suggestive of traumatic cholecystitis. To exclude additional intra-abdominal injuries, explorative laparotomy was performed. Laparoscopy was abandoned because of a previous laparotomy, but should otherwise be considered [22, 23]. If there is any doubt about possible bile duct injury, peroperative cholangiography should be performed. Non-surgical treatment is described in late posttraumatic obstructive cholecystitis in which the symptoms can be relieved by desobstruction of the common bile duct via percutaneous transhepatic cholangiography and drainage [16]. Endoscopic sphincterotomy could be an interesting alternative [13]. However, these techniques are not preferable in presence of coagulopathies. This should be considered especially in multi trauma patients and in patients with a history of alcohol abuse. Conservatively treated gallbladder contusion might be complicated by necrosis of the gallbladder wall due to local ischaemia [10]. It is obvious that cholecystectomy should be performed as soon as the diagnosis is made. In case of accompanying intra-abdominal injuries, treatment will mainly be determinated by these conditions. In the past decade the tendency to treat haemodynamically stable patients conservatively is increasingly accepted. If active haemorrhage in the haemodynamically-stable patient is suspected confirmation can be obtained by angiography. Selective embolization of the cystic artery can be performed, in other cases embolization of the hepatic artery might be necessary [10, 16]. Intrahepatic bile duct injuries will rarely require emergent surgery. Endoscopic stenting or percutaneous drainage will often be sufficient [13]. On the contrary, extrahepatic bile duct injuries might need surgical exploration in a specialised centre.
Conclusion In this article we presented an almost unique case of isolated gallbladder wall contusion. There are three important aspects we would like to emphasize. First, the kind of trauma: acute deceleration is a notorious cause of intra-abdominal injuries and should be considered in every patient after similar trauma. The second aspect is the intoxicated state of the patient. An altered consciousness due to alcohol, narcotics or other substances should play an important role in determining the diagnostic approach of the patient. One should always be aware of the unreliability of history taking and physical examination in intoxicated patients.
548
Ancillary investigations must be considered carefully and admission for observation is mandatory. The third aspect concerns the fact that alcohol abuse is known to be a predisposing factor for gallbladder injury, as it leads to distention of the gallbladder. Our patient was an intoxicated homeless man in a neglected state. Fasting is also known to cause distention of the gallbladder. However, if our patient also had been fasting before trauma was not clear. In general, gallbladder injuries are extremely rare. Ultrasound and CT are suitable imaging techniques to confirm the diagnosis. However, accompanying injuries might require additional investigations. Isolated gallbladder injury allows conservative treatment as long as no perforation or traumatic cholecystitis is present. In the latter, endoscopic or percutaneous treatment are valuable alternatives to surgery.
References 1.
Salzman S, Lutfi R, Fishman D, Doherty J, Merlotti G. Traumatic rupture of the gallbladder. J Trauma 2006;61:454–6. 2. Nishiwaki M, Ashida H, Nishimura T, Kimura M, Yagyu R, Nishioka A, Utsunomiya J, Yamamura T. Posttraumatic intragallbladder haemorrhage in a patient with liver cirrhosis. J Gastroenterol 1999;34:282–5. 3. Burgess P, Fulton RL. Gallbladder and extrahepatic biliary duct injury following abdominal trauma. Injury 1992;23:413–4. 4. Kambayashi M, Yong W, Watanabe K, Alam S. Hemobilia due to gallbladder contusion following blunt trauma – sonography and CT scanning for early detection: case report. J Trauma 1993;34:440–2. 5. Ray PD, Luchette FA, Doerr RJ. Haemorrhagic hydrops of the gallbladder. Injury 1997;28:143–5. 6. Jeffrey RB Jr, Federle MP, Laing FC, Wing VW. Computed tomography of blunt trauma to the gallbladder. J Comput Assist Tomogr 1986;10:756–8. 7. McNabney WK, Rudek R, Pemberton LB. The significance of gallbladder trauma. J Emerg Med 1990;8:277–80. 8. Soderstrom CA, Maekawa K, DuPriest RW Jr, Cowley RA. Gallbladder injuries resulting from blunt abdominal trauma. An experience and review. Ann Surg 1981;193:60–6. 9. Gupta A, Stuhlfaut JW, Fleming KW, Lucey BC, Soto JA. Blunt trauma of the pancreas and biliary tract: a multimodality imaging approach to diagnosis. Radiographics 2004;24:1381–95. 10. Sharma O. Blunt gallbladder injuries: presentation of twenty-two cases with review of the literature. J Trauma 1995;39:576–80. 11. Smith EH, Soderberg CH Jr. Traumatic rupture of the gallbladder. RI Med J 1964;47:29–30. 12. Spigos DG, Tan WS, Larson G, Palani C, Zaitoon MM, Capek V. Diagnosis of traumatic rupture of the gallbladder. Am J Surg 1981;141:731–5. 13. Clancy TE, Warren RL. Endoscopic treatment of biliary colic resulting from hemobilia after nonoperative management of blunt hepatic injury: case report and review of the literature. J Trauma 1997;43:527–9. 14. Benedict MD, Rafal R. Finding of CT and MR evaluation of gallbladder hemobilia. Emerg Radiol 2003;10:46–8.
Eur J Trauma Emerg Surg 2007 Æ No. 5 Ó URBAN & VOGEL
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15.
Sandblom P, Saegesser F, Mirkovitch V. Hepatic hemobilia: haemorrhage from the intrahepatic biliary tract, a review. World J Surg 1984;8:41–50. 16. Butler KL, Sinclair KE, Silverstein MI, Mesidor DA, Weaver WL. Posttraumatic hemobilia complicated by obstructive jaundice. J Trauma 1999;47:582–4. 17. Grant EG, Smirniotopoulos JG. Intraluminal gallbladder hematoma: sonographic evidence of hemobilia. J Clin Ultrasound 1983;11:507–9. 18. Kauzlaric D, Barmeir E. Sonography of intraluminal gallbladder hematoma. J Clin Ultrasound 1985;13:291–4. 19. Zissin R, Osadchy A, Shapiro-Feinberg M, Gayer G. CT of a thickened-wall gallbladder. Br J Radiol 2003;76:137–43. 20. Scharling ES, Geisinger KR. Case of the day. Hemobilia: intraluminal gallbladder hematoma. J Ultrasound Med 1993;12:244–5. 21. Gottesman L, Marks RA, Khoury PT, Moallem AG, Wichern WA Jr. Diagnosis of isolated perforation of the gallbladder following
Eur J Trauma Emerg Surg 2007 Æ No. 5 Ó URBAN & VOGEL
blunt trauma using sonography and CT scan. J Trauma 1984;24:280–1. 22. Shope TR, Bass TL, Haluck RS. Laparoscopic management of traumatic hemorrhagic cholecystitis. JSLS 2004;8:93–5. 23. Herek O, Yildiran N. Gallbladder hydrops caused by intraluminal clot in hemobilia: an unusual complication of hepatic trauma in childhood. J Pediatr Gastroenterol Nutr 2001;33:92–3.
Address for Correspondence Tudyka Vera Department of Surgery Maasland Ziekenhuis Sittard Walramstraat 23 Sittard, 6131 BK The Netherlands e-mail: [email protected]
549
European Journal of Trauma and Emergency Surgery
Isolated Gallbladder Injury after Blunt Abdominal Trauma: a Case Report and Review Tudyka Vera1, Toebosch Susan2, Zuidema Wietse3
Abstract We describe a case of isolated gallbladder contusion after deceleration trauma. On admission, no evident signs of intra-abdominal injury were present. However, after 24 h observation an explorative laparotomy was performed because of persistent abdominal complaints. A contusion of the gallbladder wall was found with intraluminal haematoma and a cholecystectomy was performed. Isolated injury of the gallbladder after blunt trauma is extremely rare. Risk factors are distention of the gallbladder, deceleration trauma and the presence of a relatively mobile gallbladder. Clinical signs often are very subtle. Delayed presentation is common with signs of hemobilia or obstruction due to intraluminal clots. Ultrasound and computed tomography are suitable diagnostic tools. However, the diagnosis is often missed if no other injuries are present. Signs pointing to gallbladder injury are a collapsed gallbladder with pericholecystic fluid or a hydroptic gallbladder with intraluminal hematoma. Hepatobiliary scintigraphy or angiography might be necessary if additional injuries are suspected. The choice of treatment depends on the kind of injury. Contusion of the gallbladder allows conservative treatment, but in case of a rupture, surgery will be necessary. Accompanying bile duct injuries can be treated by endoscopic stenting. If active arterial bleeding is present, selective embolization can be performed.
Key Words Gallbladder contusion Æ Abdominal trauma Æ Hemobilia Eur J Trauma Emerg Surg 2007;33:545–9 DOI 10.1007/s00068-007-6202-x
Case Report A 41-year-old homeless man was brought to the Emergency Department after falling from a height of 6 m. History taking was unreliable because of the patient being intoxicated by alcohol. Therefore the exact mechanism of the accident remained unclear. The patient complained of upper abdominal pain. Past medical history revealed addiction to illicit drugs, seropositivity for human immunodeficiency virus and a negative explorative laparotomy for a gun shot injury 15 years ago. Medications consisted of methadone, anti-retroviral drugs and an H2-blocker. On physical examination we found an agitated man with normal vital signs and a maximal Glasgow Coma Score of 15. There was upper right abdominal tenderness on palpation, but no rebound or guarding. The remainder of the physical examination was unremarkable. A chest X-ray revealed no abnormalities. A bedside ultrasound was performed and revealed no intra-abdominal fluid collections or other signs of injury to the liver, spleen, kidneys or aorta.
1
Department of Surgery, Maasland Ziekenhuis Sittard, Walramstraat 23, Sittard, 6131 BK, The Netherlands, 2 Department of Gastroenterology, University Hospital Maastricht, Maastricht, The Netherlands, 3 Department of Surgery, Academic Medical Centre Amsterdam, Amsterdam, The Netherlands. Received: November 21, 2006; revision accepted: May 15, 2007; Published Online: July 23, 2007
Eur J Trauma Emerg Surg 2007 Æ No. 5 Ó URBAN & VOGEL
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Vera T, et al. Isolated Gallbladder Injury after Blunt Abdominal Trauma
Figure 1. Hydroptic gallbladder with intraluminal hematoma.
The pancreas could not be visualized by ultrasound. Laboratory findings revealed a previously known macrocytic anemia (Hb 11.1 g/dl, MCV 133); urinalysis was negative for erythrocytes. Because of the kind of trauma and his abdominal pain, the patient was admitted to the Observation Ward. The following day the abdominal pain persisted; physical examination did not reveal any new findings. The hemoglobin had decreased to 10.2 g/dl. Computed tomography (CT) of the abdomen was performed and showed a Hydroptic gallbladder with intraluminal fluid, possibly due to hematoma (Figure 1); the common bile duct appeared to be widened. The gallbladder wall was not thickened. Liver, kidneys, pancreas and duodenum were normal. There was a small amount of fluid seen pericholecystic as well as in the right paracolic fossa. Subsequently the patient underwent explorative laparotomy to rule out gallbladder perforation. A nonperforated, macroscopically normal gallbladder was found. Further exploration of the abdomen revealed no other injuries. A cholecystectomy was performed and after opening the removed gal bladder a large intraluminal haematoma was seen. Pathologic findings confirmed the diagnosis of hemobilia due to contusion of the gallbladder wall without any signs of perforation or laceration. Postoperatively the patient recovered without any complications and was able to be discharged 5 days after surgery.
546
Review of the Literature Epidemiology Injury of the gallbladder after blunt trauma is rare. Most cases occur following penetrating trauma [1]. Isolated blunt injury of the gallbladder is practically unknown. Searching relevant English literature, we only found five reports describing isolated gallbladder contusion [2–6]. In general, in 1–3% of patients undergoing laparotomy for blunt trauma, injury to the gallbladder is found [7–9]. This low prevalence may be due to the anatomical position of the gallbladder, being protected by the rib cage and embedded in the right lobe of the liver. This explains the high incidence of other intraabdominal injuries if gallbladder injury is present. Especially injury to the liver including intra- and extrahepatic bile ducts, spleen and duodenum is found [7–9]. As a consequence, morbidity and mortality of gallbladder trauma will be highly determined by complications of the accompanying injuries. There are, however, complications occurring especially after gallbladder injury. Hematoma of the gallbladder wall can result in local ischaemia leading to necrosis and perforation or so-called ‘‘delayed rupture’’ [8, 10]. Obstructing blood clots can induce a hydroptic cholecystitis, referred to as traumatic cholecystitis [5]. Both conditions will make cholecystectomy necessary. There seem to be some factors that increase the risk for injury of the gallbladder. Distention of the gallbladder as a result of alcohol ingestion or fasting, leads to a greater vulnerability of the gallbladder for injury [2, 3, 8, 11]. In addition intoxication by alcohol may lead to relaxation of the abdominal wall, which normally offers a certain degree of protection to trauma [12]. The type of trauma, especially blunt trauma due to acute deceleration, is also thought to increase the risk of gallbladder trauma. Acute deceleration may lead to compression of the gallbladder against the spine [8]. Also, tearing of a relatively mobile gallbladder and the extrahepatic ducts can occur [3, 9]. Our case report is an example of such a trauma mechanism, describing an acute deceleration due to a fall from 6 m height. Clinical Presentation The clinical presentation of contusion of the gallbladder highly depends on the symptoms of accompanying injury to other organs. If, as in our case, no accompanying injury occurred, symptoms can be subtle and limited to slight pain in the upper (right) abdomen. If there is accompanying hepatic injury, hemobilia might be one of
Eur J Trauma Emerg Surg 2007 Æ No. 5 Ó URBAN & VOGEL
Vera T, et al. Isolated Gallbladder Injury after Blunt Abdominal Trauma
the presenting symptoms. Hemobilia is described as (traumatic) haemorrhage into the biliary tract, commonly as a result of trauma to the liver. Depending on the amount of blood loss hemobilia may present as a classic upper gastrointestinal bleeding with melaena. In 0.2–3% of blunt hepatic injury hemobilia is present [13]. However, the same happens in case of intraluminal bleeding of the gallbladder wall because of laceration or contusion [14]. This type of upper gastrointestinal bleeding is often detected not before weeks or even months after the initial injury [14–16]. In very rare cases, hemobilia leads to obstruction caused by intrabiliary clots resulting in colic pain and/or jaundice [13, 15]. As bile works as a fibrinolytic agent, most intraductal blood clots will be dissolved and will pass the sphincter of Oddi without causing obstructive signs [15]. Diagnostics As mentioned before, the clinical presentation of isolated gallbladder trauma can be non-specific, allowing conservative management without the need of an aggressive diagnostic approach. In case of accompanying intra-abdominal injury more often sophisticated diagnostic imaging or even surgery will be needed to reveal gallbladder injury in an early stage. In the review by Burgess et al. [3], describing 24 cases of traumatic hemobilia who underwent surgery, the difficulty in diagnosing biliary tract or gallbladder injury is clearly demonstrated. None of the patients were preoperatively diagnosed with gallbladder and/or bile duct injury. Diagnostic peritoneal lavage has not been proven to be useful in detecting gallbladder injury [8]. Even in the presence of bile leakage a high incidence of negative lavages for bile was found [7, 12]. Still in case of a bile stained lavage, differentiation between gallbladder, liver or duodenal injury is not possible. To recognize biliary and gallbladder injuries on imaging, appropriate diagnostic tools and clinical experience are essential. Ultrasound and CT are suitable to detect gallbladder injuries. A collapsed gallbladder with pericholecystic fluid might represent perforation, while a hydroptic gallbladder with an inhomogenic fluid mass intraluminally is suggestive for intraluminal clots [9, 15, 17–19]. If bile demonstrates a high density on CT, hemobilia is strongly suspected. Other causes of highdensity bile should be excluded. Gallstones may present with the same characteristics as intraluminal clots, demonstrating a mobile entity on ultrasound and a high-density configuration on CT [14, 20]. At the same time, differentiating between a haematoma and gallbladder carcinoma can be a challenge as well. Especially in those cases where a previous abdominal
Eur J Trauma Emerg Surg 2007 Æ No. 5 Ó URBAN & VOGEL
trauma happened weeks before presentation, there might be doubts about any association between trauma and the findings on imaging. Surgery might be the only way to get the correct diagnosis [20]. If active bleeding is suspected or melaena is present, an abdominal CT should be performed. One should realize that in case of very subtle clinical signs, especially in case of delayed presentation, melaena might be the only sign pointing to biliary or gallbladder injury [14–16]. On CT intravascular contrast will be extravasal at the site of the lesion. Selective angiography offers the advantage of the possibility to treat active haemorrhage directly by performing embolization [9, 13, 16, 18]. Bile duct injuries can be found either with CT or magnetic resonance imaging (MRI), showing liver lacerations, ascites, or perihepatic fluid collections [14]. However, hepatobiliary scintigraphy has proven to be reliable in finding bile duct injury by showing leakage of bile at the site of disruption [9, 16, 21]. Endoscopic retrograde cholangiography (ERCP) might not be the first choice as diagnostic tool, as the presence of certain conditions like duodenal perforation should be ruled out before. However, ERCP can play a major role in treatment of traumatic bile duct injuries and/or hemobilia. In our case ultrasound was performed at the Emergency Department to rule out serious intraabdominal injury. A CT scan was made following an observational period because of clinical deterioration. Nowadays, CT is often preferred over ultrasound in the haemodynamically stable patient. This offers a more detailed anatomical view of the intra-abdominal organs and is less dependent on the skills and experience of the operator. However, this requires full availability of this diagnostic tool for emergency patients without any delay. Otherwise ultrasound remains a very useful tool to detect free intra-abdominal fluids as an indirect sign of intra-abdominal injury. If biliary or gallbladder injury is suspected, additional imaging should be performed as discussed above. Management Treatment of isolated blunt gallbladder injury allows conservative management, as long as the patient is haemodynamically stable, no melaena is present and abdominal pain is under control. One could assume a lot of cases of minimal gallbladder injury remain undiagnosed and heal without complications what justifies expectant observation [8]. However, as soon as any deterioration occurs, the initial approach must be revised. Additional imaging or even surgical exploration must be considered. In our case, because of a
547
Vera T, et al. Isolated Gallbladder Injury after Blunt Abdominal Trauma
decreased haemoglobin, an abdominal CT was performed which was highly suggestive of traumatic cholecystitis. To exclude additional intra-abdominal injuries, explorative laparotomy was performed. Laparoscopy was abandoned because of a previous laparotomy, but should otherwise be considered [22, 23]. If there is any doubt about possible bile duct injury, peroperative cholangiography should be performed. Non-surgical treatment is described in late posttraumatic obstructive cholecystitis in which the symptoms can be relieved by desobstruction of the common bile duct via percutaneous transhepatic cholangiography and drainage [16]. Endoscopic sphincterotomy could be an interesting alternative [13]. However, these techniques are not preferable in presence of coagulopathies. This should be considered especially in multi trauma patients and in patients with a history of alcohol abuse. Conservatively treated gallbladder contusion might be complicated by necrosis of the gallbladder wall due to local ischaemia [10]. It is obvious that cholecystectomy should be performed as soon as the diagnosis is made. In case of accompanying intra-abdominal injuries, treatment will mainly be determinated by these conditions. In the past decade the tendency to treat haemodynamically stable patients conservatively is increasingly accepted. If active haemorrhage in the haemodynamically-stable patient is suspected confirmation can be obtained by angiography. Selective embolization of the cystic artery can be performed, in other cases embolization of the hepatic artery might be necessary [10, 16]. Intrahepatic bile duct injuries will rarely require emergent surgery. Endoscopic stenting or percutaneous drainage will often be sufficient [13]. On the contrary, extrahepatic bile duct injuries might need surgical exploration in a specialised centre.
Conclusion In this article we presented an almost unique case of isolated gallbladder wall contusion. There are three important aspects we would like to emphasize. First, the kind of trauma: acute deceleration is a notorious cause of intra-abdominal injuries and should be considered in every patient after similar trauma. The second aspect is the intoxicated state of the patient. An altered consciousness due to alcohol, narcotics or other substances should play an important role in determining the diagnostic approach of the patient. One should always be aware of the unreliability of history taking and physical examination in intoxicated patients.
548
Ancillary investigations must be considered carefully and admission for observation is mandatory. The third aspect concerns the fact that alcohol abuse is known to be a predisposing factor for gallbladder injury, as it leads to distention of the gallbladder. Our patient was an intoxicated homeless man in a neglected state. Fasting is also known to cause distention of the gallbladder. However, if our patient also had been fasting before trauma was not clear. In general, gallbladder injuries are extremely rare. Ultrasound and CT are suitable imaging techniques to confirm the diagnosis. However, accompanying injuries might require additional investigations. Isolated gallbladder injury allows conservative treatment as long as no perforation or traumatic cholecystitis is present. In the latter, endoscopic or percutaneous treatment are valuable alternatives to surgery.
References 1.
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Address for Correspondence Tudyka Vera Department of Surgery Maasland Ziekenhuis Sittard Walramstraat 23 Sittard, 6131 BK The Netherlands e-mail: [email protected]
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