Gallbladder Perforation After Acalculous Cholecystitis

Abstract

PRESENTATION OF CASEA sixty two year old female was admitted in the surgical unit of the hospital with complaints of pain in epigastrium and distension of abdomen for last 2 days. Pain was initially localised, but became generalised with the passage of time. There was no history of fever and vomiting and no other associated symptoms. There was no past history suggestive of cholelithiasis. On examination, patient was moderately dehydrated. Her BP was 100/ 70 mmHg, pulse rate was 120/mt, low in volume but regular, and respiratory rate was 24/mt shallow. Abdomen was distended with generalised tenderness on palpation and bowel sounds were absent. The systemic examination was within normal limits.Gallbladder perforation (GBP) with chemical peritonitis is a rare but life-threatening condition, which usually requires immediate surgical intervention. Most cases are the complication of acute cholecystitis associated with cholelithiasis, although acute acalculous cholecystitis or intramural vessel thrombosis can sometimes lead to gallbladder perforation. DIFFERENTIAL DIAGNOSESa. Bacterial Peritonitis after duodenal perforation. b. Chemical Peritonitis after gallbladder/ CBD perforation. CLINICAL DIAGNOSISUltrasonography of abdomen revealed small amount of collection of clear fluid without septation and gallbladder margins were not very clearly identifiable. The x-ray abdomen erect view revealed no signs of intestinal obstruction or pneumoperitoneum.Blood examination showed a white blood cell count of 10900/ mm 3 , total bilirubin level of 1.2 mg/ dL, SGPT of 47 IU/ L, serum amylase level of 338 IU/ L and serum lipase level of 155 IU/ L. Initially, the patient was treated on the line of conservative management with fluid resuscitation, supportive treatment and antibiotics with the probable diagnosis of acute cholecystitis. However, there was no relief in abdominal pain and abdominal distension also increased and repeat ultrasonography showed moderate amount of collection in abdomen. So, a perforation peritonitis was suspected.Then, laparotomy was performed the day after admission. On laparotomy, abdomen was full of bile stained fluid with partial necrotic changes in neck and body of the gall bladder.