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Free intraperitoneal cholelithiasis— A sign of traumatic perforation of the gallbladder
TheJournal ofEmergency Medicme. Vol. 1,pp.223-225. 1984
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0 1984 Pergamon Press Ltd
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FREE INTRAPERITONEAL CHOLELITHIASISA SIGN OF TRAUMATIC PERFORATION OF THE GALLBLADDER Robert
H. WOlfSOn, MD,* Ernest E. Moore, MD,t and Peter C. Murr, MD* *Resident
in Surgery, Denver General Hosprtal, Denver, Colorado TChief, Trauma Surgery, Denver General Hospital, Assocrate Professor of Surgery, University of Colorado Health Sciences Center, Denver, Colorado *Attending in Surgery, St. Joseph’s Hosprtal, Denver, Colorado Reprint address: Robert H. Wolfson, MD, Denver General Hosprtal, Department of Surgery, 777 Bannock Street, Denver CO 80204-4507
Cl Abstract-Traumatic perforation of the gallbladder is relatively infrequent and is rare as an isolated lesion. The unique aspect of this case is the diagnosis of traumatic gallbladder perforation based on plain abdominal roentgenographic evidence of free intraperitoneal cholelitbiasis. 0 Keywords - blunt trauma; abdomen; gallbladder; abdominal roentgenogram; cholecystectomy
Traumatic perforation of the gallbladder is usually discovered because of associated injury to the liver or other intraperitoneal viscera. Isolated blunt gallbladder disruption occurs in 3%’ of patients with gallbladder trauma. As an isolated injury the diagnosis is often delayed.2-4 The following details a patient presenting three days postinjury with free intraperitoneal gallstones recognized preoperatively on plain abdominal roentgenograms.
Case Report A 56-year-old white man arrived at St. Joseph’s Hospital complaining of progressive abdominal pain. He was seen three days RECEIVED: 15
June 1983; ACCEPTED:
15
earlier because of an altercation in which he was kicked in the thorax and abdomen numerous times. At that time he was mildly intoxicated, and the only positive finding was mild right anterior chest wall tenderness. The patient was sent home with a diagnosis of chest wall contusion. Over the ensuing 72 hours he developed increasing abdominal pain accompanied by nausea, vomiting, and fatigue. On returning to the emergency department the patient was lethargic and in acute distress. His temperature was 37 “C, systolic blood pressure 60 mm Hg, and pulse rate 130 beats/min. There was now perceptable ecchymosis over the right upper quadrant associated with moderate, diffuse, abdominal tenderness and diminished bowel sounds. A supine abdominal roentgenogram revealed intraperitoneal cholelithiasis, indicating perforation of the gallbladder (Figure 1). Laparotomy confirmed rupture of the gallbladder fundus with free intraperitoneal gallstones and bile. The gallbladder was additionally avulsed from the liver. Except for minor bleeding from the gallbladder fossa, the liver was not otherwise injured. The only other intraperitoneal abnormal-
September 1983 223
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Robert H. Wolfson, Ernest E. Moore, and Peter C. Murr
Figulre 1. Free intraperitoneal cholelithiasis following blunt abdominal trauma.
ity was a circumferential hematoma over the proximal common bile duct. Cholecystectomy was performed and a choledochotomy carried out in the region of the hematoma. The common duct was found to be intact and a T-tube was placed. Intraoperative cholangiography via the T-tube confirmed a normal extrahepatic biliary system. The patient’s recovery was uneventful and the T-tube was removed in the clinic 2 weeks postoperatively.
Discussion injury to the gallbladder is infrequent. In Penn’s review of 5,070 patients requiring laparotomy for acute trauma, 109 (2%) sustained gallbladder injury.3 Hall et al re-
ported that 8% of gallbladder injuries are due to blunt trauma.5 Associated injury to other intraperitoneal organs is almost invariable. In Soderstrom’s report of blunt injury to the gallbladder only 3% were isolated; liver laceration occurred in 83070, splenic in 33070, and mesenteric tear or hematoma in 30% of patients.’ The diagnosis of gallbladder trauma is rarely made preoperatively and is often delayed if it is an isolated injury. Plain abdominal roentgenographic signs are usually nonspecific.2 Moreover, normal oral cholecystography has been reported in the presence of a perforated gallbladder.’ Percutaneous transhepatic cholangiography has been suggested as a diagnostic tool, but clearly this is a technically demanding procedure.4 The reliability of ultrasonography,
Free Abdominal
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Gallstones
computed tomography, and hepatobiliary scan for this entity are not known. SoderStrom et al reported diagnostic peritoneal lavage positive for blood in patients with traumatic perforation of the gallbladder, but associated injury was presumably the source of the blood.’ Interestingly, bile was not identified in the lavage effluents. To our knowledge this is the first report of free intraperitoneal cholelithiasis as a diagnostic feature of gallbladder injury. This is probably an unusual event because a gallbladder containing stones is frequent-
ly thickened due to chronic inflammation rendering it less prone to rupture. Smith and Soderberg6 suggested three predisposing factors to gallbladder perforation: (a) normal, thin-walled gallbladder, (b) full gallbladder at the time of trauma, and (c) recent ingestion of alcohol causing increased sphincter tone at the choledochoduodenal junction.6 In our patient, typical fibrotic chronic cholecystitis had not developed, and alcohol consumption at the time of injury may have been an important causing factor.
REFERENCES 1. Soderstrom CA, Maekawa K, Dupriest R: Gallbladder injuries resulting from blunt abdominal trauma, an experience and review. Ann Surg 1981; 193:60. 2. Fielding JWL, Stratchar CC: Jaundice as a sign of
delayed gallbladder perforation following blunt abdominal trauma. Injury 1975; 6:66. 3. Penn 1: Injuries of the gallbladder. &it JSurg 1962; 491636.
4. Frank DJ, Pereiras R, Lima M: Traumatic rupture of the gallbladder with massive biliary ascitis. JAMA 1978; 240:252. 5. Hall EM, Howard JM, Jordan GL: Traumatic injuries of the gallbladder. Arch Surg 1956; 72:520. 6. Smith EH, Soderberg CH: Traumatic rupture of the gallbladder. RI Med J 1964; 47:29.
Prrnted rn the USA
Copyhght
??
Case
0 1984 Pergamon Press Ltd
Report
FREE INTRAPERITONEAL CHOLELITHIASISA SIGN OF TRAUMATIC PERFORATION OF THE GALLBLADDER Robert
H. WOlfSOn, MD,* Ernest E. Moore, MD,t and Peter C. Murr, MD* *Resident
in Surgery, Denver General Hosprtal, Denver, Colorado TChief, Trauma Surgery, Denver General Hospital, Assocrate Professor of Surgery, University of Colorado Health Sciences Center, Denver, Colorado *Attending in Surgery, St. Joseph’s Hosprtal, Denver, Colorado Reprint address: Robert H. Wolfson, MD, Denver General Hosprtal, Department of Surgery, 777 Bannock Street, Denver CO 80204-4507
Cl Abstract-Traumatic perforation of the gallbladder is relatively infrequent and is rare as an isolated lesion. The unique aspect of this case is the diagnosis of traumatic gallbladder perforation based on plain abdominal roentgenographic evidence of free intraperitoneal cholelitbiasis. 0 Keywords - blunt trauma; abdomen; gallbladder; abdominal roentgenogram; cholecystectomy
Traumatic perforation of the gallbladder is usually discovered because of associated injury to the liver or other intraperitoneal viscera. Isolated blunt gallbladder disruption occurs in 3%’ of patients with gallbladder trauma. As an isolated injury the diagnosis is often delayed.2-4 The following details a patient presenting three days postinjury with free intraperitoneal gallstones recognized preoperatively on plain abdominal roentgenograms.
Case Report A 56-year-old white man arrived at St. Joseph’s Hospital complaining of progressive abdominal pain. He was seen three days RECEIVED: 15
June 1983; ACCEPTED:
15
earlier because of an altercation in which he was kicked in the thorax and abdomen numerous times. At that time he was mildly intoxicated, and the only positive finding was mild right anterior chest wall tenderness. The patient was sent home with a diagnosis of chest wall contusion. Over the ensuing 72 hours he developed increasing abdominal pain accompanied by nausea, vomiting, and fatigue. On returning to the emergency department the patient was lethargic and in acute distress. His temperature was 37 “C, systolic blood pressure 60 mm Hg, and pulse rate 130 beats/min. There was now perceptable ecchymosis over the right upper quadrant associated with moderate, diffuse, abdominal tenderness and diminished bowel sounds. A supine abdominal roentgenogram revealed intraperitoneal cholelithiasis, indicating perforation of the gallbladder (Figure 1). Laparotomy confirmed rupture of the gallbladder fundus with free intraperitoneal gallstones and bile. The gallbladder was additionally avulsed from the liver. Except for minor bleeding from the gallbladder fossa, the liver was not otherwise injured. The only other intraperitoneal abnormal-
September 1983 223
0736-4679/84 $3.00 +- .OO
224
Robert H. Wolfson, Ernest E. Moore, and Peter C. Murr
Figulre 1. Free intraperitoneal cholelithiasis following blunt abdominal trauma.
ity was a circumferential hematoma over the proximal common bile duct. Cholecystectomy was performed and a choledochotomy carried out in the region of the hematoma. The common duct was found to be intact and a T-tube was placed. Intraoperative cholangiography via the T-tube confirmed a normal extrahepatic biliary system. The patient’s recovery was uneventful and the T-tube was removed in the clinic 2 weeks postoperatively.
Discussion injury to the gallbladder is infrequent. In Penn’s review of 5,070 patients requiring laparotomy for acute trauma, 109 (2%) sustained gallbladder injury.3 Hall et al re-
ported that 8% of gallbladder injuries are due to blunt trauma.5 Associated injury to other intraperitoneal organs is almost invariable. In Soderstrom’s report of blunt injury to the gallbladder only 3% were isolated; liver laceration occurred in 83070, splenic in 33070, and mesenteric tear or hematoma in 30% of patients.’ The diagnosis of gallbladder trauma is rarely made preoperatively and is often delayed if it is an isolated injury. Plain abdominal roentgenographic signs are usually nonspecific.2 Moreover, normal oral cholecystography has been reported in the presence of a perforated gallbladder.’ Percutaneous transhepatic cholangiography has been suggested as a diagnostic tool, but clearly this is a technically demanding procedure.4 The reliability of ultrasonography,
Free Abdominal
225
Gallstones
computed tomography, and hepatobiliary scan for this entity are not known. SoderStrom et al reported diagnostic peritoneal lavage positive for blood in patients with traumatic perforation of the gallbladder, but associated injury was presumably the source of the blood.’ Interestingly, bile was not identified in the lavage effluents. To our knowledge this is the first report of free intraperitoneal cholelithiasis as a diagnostic feature of gallbladder injury. This is probably an unusual event because a gallbladder containing stones is frequent-
ly thickened due to chronic inflammation rendering it less prone to rupture. Smith and Soderberg6 suggested three predisposing factors to gallbladder perforation: (a) normal, thin-walled gallbladder, (b) full gallbladder at the time of trauma, and (c) recent ingestion of alcohol causing increased sphincter tone at the choledochoduodenal junction.6 In our patient, typical fibrotic chronic cholecystitis had not developed, and alcohol consumption at the time of injury may have been an important causing factor.
REFERENCES 1. Soderstrom CA, Maekawa K, Dupriest R: Gallbladder injuries resulting from blunt abdominal trauma, an experience and review. Ann Surg 1981; 193:60. 2. Fielding JWL, Stratchar CC: Jaundice as a sign of
delayed gallbladder perforation following blunt abdominal trauma. Injury 1975; 6:66. 3. Penn 1: Injuries of the gallbladder. &it JSurg 1962; 491636.
4. Frank DJ, Pereiras R, Lima M: Traumatic rupture of the gallbladder with massive biliary ascitis. JAMA 1978; 240:252. 5. Hall EM, Howard JM, Jordan GL: Traumatic injuries of the gallbladder. Arch Surg 1956; 72:520. 6. Smith EH, Soderberg CH: Traumatic rupture of the gallbladder. RI Med J 1964; 47:29.