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Spontaneous gall bladder perforation: a rare condition in the differential diagnosis of acute abdomen in children
Journal of Pediatric Surgery (2011) 46, 241–243
www.elsevier.com/locate/jpedsurg
Spontaneous gall bladder perforation: a rare condition in the differential diagnosis of acute abdomen in children Ram Mohan Shukla ⁎, Dipankar Roy, Partha Pratik Mukherjee, Kaushik Saha, Biswanath Mukhopadhyay, Kartik Chandra Mandal, Kalyani SahaBasu, Shib Sankar Barman Department of Pediatric Surgery, Nil Ratan Sircar Medical College and Hospital, Kolkata-700014, India Received 8 June 2010; revised 22 August 2010; accepted 17 September 2010
Key words: Acute cholecystitis; Gallbladder perforation; Acute abdomen; Cholecystectomy; Emergency surgery in children
Abstract Gallbladder perforation is very rare in children and almost exclusively is a complication of cholecystitis, which accompanies severe inflammation of the gallbladder with or without cholelithiasis. Here we present 4 cases of spontaneous gall bladder perforation, which should be kept in mind as a condition for inclusion in the differential diagnosis of an acute abdomen in children. © 2011 Elsevier Inc. All rights reserved.
Idiopathic perforation of the gallbladder is a novel condition in the differential diagnosis of an acute abdomen in children [1]. Because the symptoms of gall bladder perforation (GBP) and uncomplicated cholecystitis are similar, the differential diagnosis may be difficult based on physical examination, laboratory tests, and radiologic methods and may not be established preoperatively [2,3]. Delay in diagnosis is the major cause of its high morbidity and mortality [4-7].
1. Case 1 A 10-year-old boy presented with fever of 3-day duration, abdominal pain, abdominal distension, and an inability to pass flatus and feces for 2 days. Physical examination ⁎ Corresponding author. 711102 West Bengal, India. Tel.: +91 09433020426. E-mail addresses: [email protected] (R.M. Shukla), [email protected] (B. Mukhopadhyay). 0022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.09.043
demonstrated the presence of guarding, rigidity, and rebound tenderness more so in the right lower quadrant. A plain abdominal radiograph showed air fluid levels, but no free air. After resuscitation, an emergency abdominal exploration was performed with the probable diagnosis of perforated appendicitis. At exploration, approximately 100 mL of bilestained fluid was found with a large perforation in the fundus of the gall bladder. Partial cholecystectomy was done through the neck of the gall bladder without extensive portal dissection. A drain was placed in the gall bladder bed. Histologic examination revealed nonspecific inflammatory changes in the gall bladder. The ascitic fluid was sterile. The postoperative period was uneventful, and the drain was removed on the 5th postoperative day after a normal abdominal sonograph was obtained. The child is doing well 3 years later.
2. Case 2 An 8-year-old boy presented in emergency room with fever of 2-day duration, abdominal pain, and abdominal distension.
242
R.M. Shukla et al. on, and a perforation in the gall bladder was noted. Cholecystectomy was done; a drain was placed in the gall bladder bed. Histologic examination again showed nonspecific inflammatory changes. The child is doing well 2 months after surgery.
5. Discussion
Fig. 1
Perforation in gall bladder.
Physical examination demonstrated the presence of guarding, tenderness, and rigidity, more so in the right side of abdomen. A plain abdominal radiograph showed multiple air fluid levels, but no free air under the diaphragm. Emergency laparotomy through a McBurney incision was done, with the probable diagnosis of perforated appendix, but appendix was normal and gall bladder was found to be perforated (Fig. 1). The McBurney incision was extended upward, and a cholecystectomy was done with placement of an intraperitoneal drain. Histology revealed nonspecific inflammatory changes in the gall bladder. The ascitic fluid culture was positive for Escherichia coli. The postoperative period was uneventful. On follow-up, the child is doing well 2 years later.
3. Case 3 A 6-year-old boy presented with fever, abdominal pain, and distension of 2-day duration and nonbilious vomiting for 1 day. Physical examination demonstrated guarding, tenderness, and rigidity, more so in the right upper abdomen. The abdomen was tender on percussion, and liver dullness was not obliterated. Peristaltic sounds were absent. A plain abdominal radiograph showed dilated bowel loops, but no free air. Emergency laparotomy was done with the probable diagnosis of ruptured liver abscess, but multiple perforations were found in the gall bladder. Cholecystectomy was done with placement of an intraperitoneal drain. Histology revealed nonspecific inflammatory changes in the gall bladder. The ascitic fluid culture was sterile. The postoperative period was uneventful, and the child is doing well 6 months later.
4. Case 4 A 4-month-old boy presented with features of an acute abdomen and, after necessary investigations, was operated
In 2% to 11% of acute cholecystitis patients, inflammation may progress to cause ischemia and necrosis of the gall bladder, resulting in GBP [2,6,8]. The most common site of GBP is the fundus because this is the most distal part with regard to blood supply [3,8]. Spontaneous perforation of the gall bladder may be caused by an inflammatory reaction and weakness of its wall in the course of the disease. Histologic examination shows inflammatory changes in the gall bladder that were also noticed in our patients. The clinical features suggestive of GBP are nonspecific. Detecting GBP requires a high degree of clinical suspicion, especially in the pediatric population. Hence, surgeons must bear in mind the possibility of this rare condition in the differential diagnosis while treating any pediatric patient presenting with an acute abdomen. Paracentesis may reveal bile-stained ascitic fluid [9]. Plain abdominal radiographs may not show pneumoperitoneum as was noted in our patients, and hence, they are not always helpful. Ultrasonography, computed tomography (CT) scan, and radionuclide scan are used for confirmation of the diagnosis. Although standard abdominal CT has an important role in diagnosing gallbladder perforation, upper abdominal CT for acute cholecystitis in which pericholecystic fluid is found by ultrasonography may increase the rate of preoperative diagnosis of gallbladder perforation [10]. Niemeier [11] in 1934 classified gallbladder perforation and generalized biliary peritonitis as acute or type1 GBP, pericholecystic abscess and localized peritonitis as subacute or type 2 GBP, and cholecystenteric fistula as chronic or type 3 GBP. This classification is still in use. Most of our patients presented with type 1 perforation and were managed accordingly. Various surgical procedures used for GBP as mentioned in literature are partial cholecystectomy with external biliary drainage, temporary cholecystostomy with external biliary drainage, and cholecystectomy [8,12,13]. Cholecystectomy is the preferred treatment with a reasonable outcome [13]. Early diagnosis of gallbladder perforation and prompt surgical intervention are of crucial importance. Gall bladder perforation should be included in the differential diagnosis in children with an acute abdomen.
References [1] Estevao-Costa J, Soares-Oliveira M, Lopes JM, et al. Idiopathic perforation of the gallbladder: a novel differential diagnosis of acute abdomen. J Pediatr Gastroenterol Nutr 2002;35:88-9.
Spontaneous gall bladder perforation [2] Bedirli A, Sakrak O, Sozuer EM, et al. Factors effecting the complications in the natural history of acute cholecystitis. Hepatogastroenterology 2001;48:1275-8. [3] Isch JH, Finneran JC, Nahrwold DL. Perforation of the gallbladder. Am J Gastroenterol 1971;55:451-8. [4] Roslyn JJ, Thompson Jr JE, Darvin H, et al. Risk factors for gallbladder perforation. Am J Gastroenterol 1987;82:636-40. [5] Ong CL, Wong TH, Rauff A. Acute gall bladder perforation—a dilemma in early diagnosis. Gut 1991;32:956-8. [6] Menakuru SR, Kaman L, Behera A, et al. Current management of gall bladder perforations. ANZ J Surg 2004;74:843-6. [7] Doherty GM, Way LW. Biliary tract. In: Way LW, Doherty GM, editors. Current surgical diagnosis & treatment. 11th ed. New York: McGraw-Hill; 2003. p. 595-624.
243 [8] Abu-Dalu J, Urca I. Acute cholecystitis with perforation into the peritoneal cavity. Arch Surg 1971;102:108-10. [9] Sharma SB, Gupta V, Sharma V. Spontaneous gall bladder perforation: a rare entity in infants. Indian J Gastroenterol 2004;23: 75-6. [10] Derici H, Kara C, Dogan Bozdag A, et al. Diagnosis and treatment of gallbladder perforation. World J Gastroenterol 2006;12:7832-6. [11] Niemeier OW. Acute free perforation of the gall bladder. Ann Surg 1934;99:922-4. [12] Nambirajan L, Chandrasekharam VV, Gupta AK, et al. Spontaneous neonatal gallbladder perforation. Trop Gastroenterol 2000;21:190-1. [13] Pandey A, Gangopadhyay AN, Kumar V. Gall bladder perforation as a complication of typhoid fever. Saudi J Gastroenterol 2008; 14:213.
www.elsevier.com/locate/jpedsurg
Spontaneous gall bladder perforation: a rare condition in the differential diagnosis of acute abdomen in children Ram Mohan Shukla ⁎, Dipankar Roy, Partha Pratik Mukherjee, Kaushik Saha, Biswanath Mukhopadhyay, Kartik Chandra Mandal, Kalyani SahaBasu, Shib Sankar Barman Department of Pediatric Surgery, Nil Ratan Sircar Medical College and Hospital, Kolkata-700014, India Received 8 June 2010; revised 22 August 2010; accepted 17 September 2010
Key words: Acute cholecystitis; Gallbladder perforation; Acute abdomen; Cholecystectomy; Emergency surgery in children
Abstract Gallbladder perforation is very rare in children and almost exclusively is a complication of cholecystitis, which accompanies severe inflammation of the gallbladder with or without cholelithiasis. Here we present 4 cases of spontaneous gall bladder perforation, which should be kept in mind as a condition for inclusion in the differential diagnosis of an acute abdomen in children. © 2011 Elsevier Inc. All rights reserved.
Idiopathic perforation of the gallbladder is a novel condition in the differential diagnosis of an acute abdomen in children [1]. Because the symptoms of gall bladder perforation (GBP) and uncomplicated cholecystitis are similar, the differential diagnosis may be difficult based on physical examination, laboratory tests, and radiologic methods and may not be established preoperatively [2,3]. Delay in diagnosis is the major cause of its high morbidity and mortality [4-7].
1. Case 1 A 10-year-old boy presented with fever of 3-day duration, abdominal pain, abdominal distension, and an inability to pass flatus and feces for 2 days. Physical examination ⁎ Corresponding author. 711102 West Bengal, India. Tel.: +91 09433020426. E-mail addresses: [email protected] (R.M. Shukla), [email protected] (B. Mukhopadhyay). 0022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2010.09.043
demonstrated the presence of guarding, rigidity, and rebound tenderness more so in the right lower quadrant. A plain abdominal radiograph showed air fluid levels, but no free air. After resuscitation, an emergency abdominal exploration was performed with the probable diagnosis of perforated appendicitis. At exploration, approximately 100 mL of bilestained fluid was found with a large perforation in the fundus of the gall bladder. Partial cholecystectomy was done through the neck of the gall bladder without extensive portal dissection. A drain was placed in the gall bladder bed. Histologic examination revealed nonspecific inflammatory changes in the gall bladder. The ascitic fluid was sterile. The postoperative period was uneventful, and the drain was removed on the 5th postoperative day after a normal abdominal sonograph was obtained. The child is doing well 3 years later.
2. Case 2 An 8-year-old boy presented in emergency room with fever of 2-day duration, abdominal pain, and abdominal distension.
242
R.M. Shukla et al. on, and a perforation in the gall bladder was noted. Cholecystectomy was done; a drain was placed in the gall bladder bed. Histologic examination again showed nonspecific inflammatory changes. The child is doing well 2 months after surgery.
5. Discussion
Fig. 1
Perforation in gall bladder.
Physical examination demonstrated the presence of guarding, tenderness, and rigidity, more so in the right side of abdomen. A plain abdominal radiograph showed multiple air fluid levels, but no free air under the diaphragm. Emergency laparotomy through a McBurney incision was done, with the probable diagnosis of perforated appendix, but appendix was normal and gall bladder was found to be perforated (Fig. 1). The McBurney incision was extended upward, and a cholecystectomy was done with placement of an intraperitoneal drain. Histology revealed nonspecific inflammatory changes in the gall bladder. The ascitic fluid culture was positive for Escherichia coli. The postoperative period was uneventful. On follow-up, the child is doing well 2 years later.
3. Case 3 A 6-year-old boy presented with fever, abdominal pain, and distension of 2-day duration and nonbilious vomiting for 1 day. Physical examination demonstrated guarding, tenderness, and rigidity, more so in the right upper abdomen. The abdomen was tender on percussion, and liver dullness was not obliterated. Peristaltic sounds were absent. A plain abdominal radiograph showed dilated bowel loops, but no free air. Emergency laparotomy was done with the probable diagnosis of ruptured liver abscess, but multiple perforations were found in the gall bladder. Cholecystectomy was done with placement of an intraperitoneal drain. Histology revealed nonspecific inflammatory changes in the gall bladder. The ascitic fluid culture was sterile. The postoperative period was uneventful, and the child is doing well 6 months later.
4. Case 4 A 4-month-old boy presented with features of an acute abdomen and, after necessary investigations, was operated
In 2% to 11% of acute cholecystitis patients, inflammation may progress to cause ischemia and necrosis of the gall bladder, resulting in GBP [2,6,8]. The most common site of GBP is the fundus because this is the most distal part with regard to blood supply [3,8]. Spontaneous perforation of the gall bladder may be caused by an inflammatory reaction and weakness of its wall in the course of the disease. Histologic examination shows inflammatory changes in the gall bladder that were also noticed in our patients. The clinical features suggestive of GBP are nonspecific. Detecting GBP requires a high degree of clinical suspicion, especially in the pediatric population. Hence, surgeons must bear in mind the possibility of this rare condition in the differential diagnosis while treating any pediatric patient presenting with an acute abdomen. Paracentesis may reveal bile-stained ascitic fluid [9]. Plain abdominal radiographs may not show pneumoperitoneum as was noted in our patients, and hence, they are not always helpful. Ultrasonography, computed tomography (CT) scan, and radionuclide scan are used for confirmation of the diagnosis. Although standard abdominal CT has an important role in diagnosing gallbladder perforation, upper abdominal CT for acute cholecystitis in which pericholecystic fluid is found by ultrasonography may increase the rate of preoperative diagnosis of gallbladder perforation [10]. Niemeier [11] in 1934 classified gallbladder perforation and generalized biliary peritonitis as acute or type1 GBP, pericholecystic abscess and localized peritonitis as subacute or type 2 GBP, and cholecystenteric fistula as chronic or type 3 GBP. This classification is still in use. Most of our patients presented with type 1 perforation and were managed accordingly. Various surgical procedures used for GBP as mentioned in literature are partial cholecystectomy with external biliary drainage, temporary cholecystostomy with external biliary drainage, and cholecystectomy [8,12,13]. Cholecystectomy is the preferred treatment with a reasonable outcome [13]. Early diagnosis of gallbladder perforation and prompt surgical intervention are of crucial importance. Gall bladder perforation should be included in the differential diagnosis in children with an acute abdomen.
References [1] Estevao-Costa J, Soares-Oliveira M, Lopes JM, et al. Idiopathic perforation of the gallbladder: a novel differential diagnosis of acute abdomen. J Pediatr Gastroenterol Nutr 2002;35:88-9.
Spontaneous gall bladder perforation [2] Bedirli A, Sakrak O, Sozuer EM, et al. Factors effecting the complications in the natural history of acute cholecystitis. Hepatogastroenterology 2001;48:1275-8. [3] Isch JH, Finneran JC, Nahrwold DL. Perforation of the gallbladder. Am J Gastroenterol 1971;55:451-8. [4] Roslyn JJ, Thompson Jr JE, Darvin H, et al. Risk factors for gallbladder perforation. Am J Gastroenterol 1987;82:636-40. [5] Ong CL, Wong TH, Rauff A. Acute gall bladder perforation—a dilemma in early diagnosis. Gut 1991;32:956-8. [6] Menakuru SR, Kaman L, Behera A, et al. Current management of gall bladder perforations. ANZ J Surg 2004;74:843-6. [7] Doherty GM, Way LW. Biliary tract. In: Way LW, Doherty GM, editors. Current surgical diagnosis & treatment. 11th ed. New York: McGraw-Hill; 2003. p. 595-624.
243 [8] Abu-Dalu J, Urca I. Acute cholecystitis with perforation into the peritoneal cavity. Arch Surg 1971;102:108-10. [9] Sharma SB, Gupta V, Sharma V. Spontaneous gall bladder perforation: a rare entity in infants. Indian J Gastroenterol 2004;23: 75-6. [10] Derici H, Kara C, Dogan Bozdag A, et al. Diagnosis and treatment of gallbladder perforation. World J Gastroenterol 2006;12:7832-6. [11] Niemeier OW. Acute free perforation of the gall bladder. Ann Surg 1934;99:922-4. [12] Nambirajan L, Chandrasekharam VV, Gupta AK, et al. Spontaneous neonatal gallbladder perforation. Trop Gastroenterol 2000;21:190-1. [13] Pandey A, Gangopadhyay AN, Kumar V. Gall bladder perforation as a complication of typhoid fever. Saudi J Gastroenterol 2008; 14:213.