Gallbladder Perforation

Gallbladder perforation is a rupture of the gallbladder wall from ischaemia and necrosis, releasing bile into the peritoneum or adjacent structures.

• Complicates 2 to 11% of acute cholecystitis; mortality 12 to 42%.
• Risk factors: age over 60, diabetes, atherosclerosis, immunosuppression, delayed presentation, gangrenous cholecystitis, cystic duct obstruction, trauma, malignancy.
• Niemeier classification: type I free perforation with generalised bile peritonitis; type II localised pericholecystic abscess; type III cholecystoenteric fistula (including gallstone ileus).
• Most common site is the fundus.

• Type I: sudden severe abdominal pain, peritonitis, fever, shock.
• Type II: persistent right upper quadrant pain, fever, palpable mass, leucocytosis with fluctuance.
• Type III: sometimes relief of pain, then small bowel obstruction (gallstone ileus) or diarrhoea.
• Elderly diabetics may have subtle signs.
• Features of sepsis: tachycardia, hypotension, oliguria.

• Leucocytosis, raised CRP, lactate, bilirubin, liver tests; blood cultures.
• Ultrasound: gallbladder wall defect, pericholecystic or free fluid, abscess, stones outside lumen.
• CT with contrast is the investigation of choice: wall discontinuity, gas, fluid collections, abscess, fistula, pneumobilia and bowel obstruction.
• Plain radiograph: pneumoperitoneum (uncommon), air in biliary tree.
• Intraoperative confirmation.
• Differentiate from perforated peptic ulcer, appendicitis, pancreatitis.

• Resuscitation: IV fluids, oxygen, analgesia, early broad spectrum antibiotics (piperacillin tazobactam 4.5 g IV every 6 hours; meropenem 1 g every 8 hours in septic shock) with source control.
• Type I: urgent laparotomy or laparoscopy, cholecystectomy, peritoneal lavage and drainage.
• Type II: cholecystectomy with abscess drainage, or percutaneous drainage first in unstable patients with interval cholecystectomy.
• Type III: treat the fistula and gallstone ileus (enterolithotomy with or without cholecystectomy and fistula closure).
• Subtotal cholecystectomy (fenestrating or reconstituting) if dissection is hazardous, with drain.
• Percutaneous cholecystostomy for patients unfit for surgery.
• ICU care for septic shock; correct coagulopathy; glycaemic control.
• Postoperative complications: bile leak, wound infection, subphrenic abscess. Antibiotics for 4 to 7 days after source control.