Different outcomes of spontaneous gall bladder perforation owing to timing of surgical intervention: report of 2 cases

Nawaz M. Dakhani, Yamanur P. Lamani


Gall bladder perforation (GBP) is a rare life-threatening complication with a high mortality due to atypical clinical presentation and delay in diagnosis due to atypical clinical presentation. Case report 1, 70-year-old female presented with complaints of pain abdomen, vomiting and blackish pigmentation over abdomen since a week. She was in shock on presentation, with necrotic patch over abdomen and abscess collection at umbilicus. Ultrasound revealed GBP at fundus with thick collection in gastrohepatic recess with overlying abdominal wall cellulitis. CECT was not possible and the patient could not be taken for surgery due to unstable vitals and expired the next day. Case report 2, a 68-year-old male presented with complaints of pain abdomen over right side with vomiting. Abdomen was tender diffusely with guarding in right hypochondrium. Ultrasound showed distended gall bladder (GB) with multiple calculi. Magnetic resonance cholangiopancreatography (MRCP) showed a GBP at fundus with pericholecystic collection extending into hepatogastric recess. He underwent total cholecystectomy and post-operative period was uneventful. Acute cholecystitis has a perforation rate of 2-11% due to cystic duct obstruction, ischemia and necrosis. Our first patient had type-III GBP and was in shock and did not survive due to bad condition on arrival whereas the second patient had type-I GBP and underwent cholecystectomy without any complications. Type-I and type-II GBP as proposed by Niemeier have better outcomes compared to type-III. Rapid diagnosis and surgical intervention are very much necessary for reducing mortality as they rarely present with typical signs and symptoms of perforation.



Gall bladder, Perforation, Cholecystitis, Niemeier classification

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Date RS, Thrumurthy SG, Whiteside S, Umer MA, Pursnani KG, Ward JB et al. Gallbladder perforation: case series and systematic review. Int J Surg. 2012;10(2):63-8.

Nandyala VNR, Pallam P, Chintakindi S, Pallagani L, Kundarapu G. Gall bladder perforation - is it still a diagnostic dilemma: a retrospective study. Int Surg J. 2016;3(2):609-13.

Duncan J. Gangrene of the gallbladder; extravasation of the bile: peritonitis; death. North J Med. 1844;2:151-3.

Chiapponi C, Wirth S, Siebeck M. Acute gallbladder perforation with gallstones spillage in a cirrhotic patient. Worl J Emerg Surg. 2010;5:11.

Singal R, Mittal A, Gupta S, Singh B, Jain P. Management of gall bladder perforation evaluation on ultrasonography: report of six rare cases with review of literature. J Med Life. 2011;4(4):364-71

Lein HH, Huang CS. Male gender: risk factor for severe symptomatic cholelithiasis. World J Surg. 2002;26(5):598-601.

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(2):128-31.

Estevão-Costa J, Soares-Oliveira M, Lopes JM, Carvalho JL. Idiopathic perforation of the gallbladder: a novel differential diagnosis of acute abdomen. J Pediatr Gastroenterol Nutr. 2002;35(1):88-9.

Arora L, Mir MA, Chadha P, Ali M, Gupta S. Case series of spontaneous gall bladder perforation and review of literature. Int Surg J. 2015;2:406-10.

Gunasekaran G, Naik D, Gupta A, Bhandari V, Kuppusamy M, Kumar G et al. Gallbladder perforation: a single center experience of 32 cases. Korean J Hepatobiliary Pancreat Surg. 2015;19(1):6-10.

Niemeier OW. Acute free perforation of the gallbladder. Ann Surg. 1934;99:922-4.

Fletcher AG, Ravdin IS. Perforation of the gallbladder. Am J Surg. 1951;81:178-85.

Roslyn J, Busuttil RW. Perforation of the gallbladder. A frequently mismanaged condition. Am J Surg. 1979;137:307-12.

Anderson BB, Nazem A. Perforations of the gallbladder and cholecystobiliary fistulae: a review of management and a new classification. J Natl Med Assoc. 1987;79:393-9.

Singh K, Singh A, Vidyarthi SH, Jindal S, Thounaojam CK. Spontaneous Intrahepatic Type II Gallbladder Perforation: A Rare Cause of Liver Abscess- Case Report. J Clin Diagn Res. 2013;7(9):2012-4.

Kundan M, Chintamani, Kumari A. Gall Bladder Perforation: Still an Enigma in Tropics. Ind J Surg. 2019;81:277-83.

Ponten JB, Selten J, Puylaert JBCM, Bronkhorst MWGA. Perforation of the gallbladder: a rare cause of acute abdominal pain. J Surg Case Repo. 2015;2:1-2.