Diagnosis of traumatic rupture of the gallbladder

Isolated Traumatic Gallbladder Injury: A Rare Case

The prevalence of gallbladder injury in a traumatic event is rare, occurring in only 1.9%-2.0% of all abdominal traumas. Isolated gallbladder injuries, without any damage to surrounding organs or tissues, are even less common. Presenting symptoms are often nonspecific, and imaging modalities of ultrasound (US) and CT are usually relied upon to diagnose gallbladder injury accurately. Identifying and strategically treating cases of gallbladder injury, through reviewing this case report, are important for patient outcomes. We present a case of isolated gallbladder injury in a 27-year-old male after sustaining blunt-force abdominal trauma from a snowmobile injury. The patient presented to the emergency department (ED) three days after the initial injury with complaints of significant abdominal pain associated with eating solid food. Upon workup, he was found to have an isolated traumatic gallbladder injury for which a laparoscopic cholecystectomy was performed, and the patient was discharged with no complications. Gallbladder injury, with no evidence of other intra-abdominal injuries, is rare and often not considered in the differential for a trauma patient. Delayed intervention is associated with adverse patient outcomes, emphasizing the need to consider gallbladder injuries in patients presenting with abdominal pain, especially with a history of chronic alcohol use.

Isolated gallbladder injury in a case of blunt abdominal trauma

The diagnosis of blunt injury to the gallbladder may constitute a significant challenge to the diagnostician. There is often a delay in presentation with non-specific clinical symptoms. In the absence of reliable clinical symptoms, diagnostic imaging becomes an invaluable tool in the rapid identification of gallbladder injury. We present a case of isolated gallbladder injury following blunt abdominal trauma which was diagnosed by computed tomography and subsequently confirmed by cholecystectomy.

Isolated Gallbladder Injury after Blunt Abdominal Trauma: a Case Report and Review

We describe a case of isolated gallbladder contusion after deceleration trauma. On admission, no evident signs of intra-abdominal injury were present. However, after 24 h observation an explorative laparotomy was performed because of persistent abdominal complaints. A contusion of the gallbladder wall was found with intraluminal haematoma and a cholecystectomy was performed. Isolated injury of the gallbladder after blunt trauma is extremely rare. Risk factors are distention of the gallbladder, deceleration trauma and the presence of a relatively mobile gallbladder. Clinical signs often are very subtle. Delayed presentation is common with signs of hemobilia or obstruction due to intraluminal clots. Ultrasound and computed tomography are suitable diagnostic tools. However, the diagnosis is often missed if no other injuries are present. Signs pointing to gallbladder injury are a collapsed gallbladder with pericholecystic fluid or a hydroptic gallbladder with intraluminal hematoma. Hepatobiliary scintigraphy or angiography might be necessary if additional injuries are suspected. The choice of treatment depends on the kind of injury. Contusion of the gallbladder allows conservative treatment, but in case of a rupture, surgery will be necessary. Accompanying bile duct injuries can be treated by endoscopic stenting. If active arterial bleeding is present, selective embolization can be performed.

Injuries distracting from intraabdominal injuries after blunt trauma

While most conscious patients with severe intraabdominal injuries (IAI) will usually present with either abdominal pain or tenderness, there is a small group of awake and alert patients in whom the physical examination will be falsely negative because of the presence of associated extraabdominal ("distracting") injuries. We sought to define the types of extraabdominal injuries that could lead to a false negative physical examination for potentially severe IAI in adult victims of blunt trauma. This study was prospectively performed on consecutive blunt trauma patients over a 14-month period in our level I trauma center. Inclusion criteria were as follows: (1) Glasgow Coma Scale score of 15; (2) age 18 years or older; and (3) computed tomography (CT) of the abdomen or diagnostic peritoneal lavage (DPL) performed regardless of initial physical examination findings. Patients were questioned specifically about the presence of abdominal pain and the initial abdominal examination was documented in addition to other extraabdominal injuries. Abdominal injuries were considered to be present based upon either abdominal CT findings or a positive DPL. Patients with and without abdominal pain or tenderness were compared for the presence of IAI. A total of 350 patients were enrolled. There were 142 patients with neither abdominal pain nor tenderness (group 1) and 208 patients with either or both (group 2). Ten of the 142 patients (7.0%) in group 1 had IAI compared with 44 of the 208 patients (21.2%) in group 2 (P = .0003). Presence of pain and/or tenderness had a sensitivity of 82%, a specificity of 45%, a positive predictive value of 21%, and negative predictive value of 93%. All 10 patients in group 1, and 36 of the 44 group 2 patients, had associated extraabdominal injuries. Although the presence of abdominal pain or tenderness was associated with a significantly higher incidence of IAI, the lack of these findings did not preclude IAI.

Non-surgical trauma to the extrahepatic biliary tract

Non-surgical trauma to the extrahepatic biliary tract is uncommon and encountered only rarely by surgeons outside specialist hepatobiliary centres. Such injury often results in significant morbidity and mortality. This review outlines the incidence, classification, mechanisms of injury, presentation, diagnostic techniques and management options. Depending on the type of biliary injury identified, an optimal method of repair is suggested. Recommendations are made for surgeons who encounter this type of injury and do not have the appropriate expertise for definitive management.

Gallbladder and extrahepatic biliary duct injury following abdominal trauma

Extrahepatic biliary tract and gallbladder injuries are rare, but many occur after both blunt and penetrating abdominal trauma. During a 5-year period, 24 patients requiring laparotomy for abdominal trauma were found to have an extrahepatic biliary tract injury, representing 13 per cent of all patients admitted with hepatic trauma during the same period. The majority of patients had injury to the gallbladder; only one case of common bile duct injury was identified. Of the patients, 50 per cent had an associated hepatic injury; 17 per cent had important pancreatic trauma. Isolated gallbladder injury occurred in only 8 per cent of patients. The overall mortality associated with gallbladder trauma was 16 per cent. This uncommon injury usually results from severe trauma and is associated with a high incidence of other major visceral injuries.

The significance of gallbladder trauma

This study reviewed patients with gallbladder trauma over a 14-year period treated at Truman Medical Center to determine the complications, associated injuries, and mortality rate. Fourteen patients had gallbladder trauma, 12 penetrating and two blunt. All patients underwent cholecystectomy and 10 had 3 or more associated injuries that required operative care. There were no biliary duct injuries or postoperative biliary complications. Seven patients had postoperative wound, pulmonary, or abdominal infections. There was one mortality due to delayed splenic hematoma, myocardial infarction, and cardiac dysrhythmia. Gallbladder trauma was always associated with significant multi-organ injuries that required early operative intervention.

PIPIDA scan diagnosis of traumatic rupture of the gallbladder

Eighteen days after injury, a patient was evaluated for bilious ascites with a 99mTc-PIPIDA (paraisopropyliminodiacetic acid) scan. A ruptured gallbladder was shown, and this finding was confirmed at exploration. Radionuclide scanning offers a sensitive, non-invasive approach for delineating disruption of the biliary tract, and should be considered when such a defect is suspected.