Isolated blunt traumatic gallbladder perforation demonstrated on MDCT and post-cholecystectomy bile leak revealed on Gd-EOB-DTPA (Primovist) enhanced MRCP

Isolated Gallbladder Injury Secondary to Blunt Abdominal Trauma

A 60-year-old male was admitted to our major level 1 trauma centre following a fall from the fourth storey of a car park and landing initially on his feet on concrete. The primary survey was unremarkable apart from abdominal pain and localised peritonism in the right upper quadrant and lower lumbar midline pain. The secondary survey revealed bilateral complex calcaneal fractures, multiple vertebral fractures and sternal fracture. A trauma CT scan showed pericholecystic fluid and described by the radiology team either as cholecystitis picture or possible disruption of the gallbladder wall. Based on the patient’s stable presentation, the decision was made for a diagnostic laparoscopy to explore possible gallbladder injury and other concomitant injuries. 

Operative findings showed free bile in the right upper quadrant and right paracolic gutter and small amount of blood. The gallbladder did not have an obvious site of perforation but had a necrotic appearance. No further injuries identified laparoscopically after checking small and large bowel, and since no obvious perforation was identified, the decision was made to convert to laparotomy and duodenal exploration. On laparotomy, there was no evidence of duodenal or pancreatic injury on Kocher’s manoeuvre and ligament of Trietz mobilisation. The gall bladder wall was stained and leaking bile, therefore a standard retrograde cholecystectomy was performed. No further intra-abdominal injuries were identified during the laparotomy. The patient made an unremarkable recovery. He was discharged home with physiotherapy for rehabilitation.

We recommend a diagnostic laparoscopy and cholecystectomy for such injuries with a low threshold for duodenal exploration (Kocherization) if the perforation site is not obvious based on the high incidence of concomitant duodenal injuries.

Detection and localization of bile duct leaks after cholecystectomy using Gd-EOB-DTPA-enhanced MR cholangiography: retrospective study of 16 patients

OBJECTIVE

To determine if gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance (MR) cholangiography can detect and localize bile duct leaks in postcholecystectomy patients.

MATERIAL AND METHODS

Four blinded independent radiologists performed a retrospective review of 16 consecutive patients who underwent MR cholangiography with intravenous Gd-EOB-DTPA for the evaluation of possible biliary leak. Image quality, ductal opacification, and presence and location of any bile leak were evaluated. An independent observer determined the criterion standard using a consensus of all chart, clinical, and imaging findings.

RESULTS

All 6 bile leaks confirmed at endoscopic retrograde cholangiopancreatography were diagnosed by all reviewers (sensitivity, 100%). Of the 10 patients with no leak, only one reader incorrectly diagnosed a bile leak in a single case (specificity, 98%). The accuracy for detection of the site of leak with Gd-EOB-DTPA-enhanced MR cholangiography was 80%.

CONCLUSION

Gadolinium-EOB-DTPA-enhanced MR can detect bile leaks with a high sensitivity and specificity.

Gd-BOPTA-enhanced MR cholangiography findings in gall bladder perforation

Gall bladder perforation is a rare condition which is associated with significant mortality and morbidity. Here, we report a case of spontaneous gall bladder perforation following acute calculous cholecystitis with pericholecystic abscess identified on Gd-BOPTA-enhanced MR cholangiography (MRC) prior to laparoscopic surgery. The gall bladder perforation was confirmed via surgery with unremarkable recovery. To the best of our knowledge, this is the first report of Gd-BOPTA-enhanced MRC for this purpose.