Gallbladder perforation: diagnostic utility of cholescintigraphy in suggested subacute or chronic cases

Comparison of Clinical and Radiologic Findings Between Perforated and Non-Perforated Choledochal Cysts in Children

OBJECTIVE

To compare the clinical and radiologic findings between perforated and non-perforated choledochal cysts in children.

MATERIALS AND METHODS

Fourteen patients (mean age ± standard deviation, 1.7 ± 1.2 years) with perforated choledochal cysts (perforated group) and 204 patients (3.6 ± 3.8 years) with non-perforated choledochal cysts (non-perforated group) were included between 2000 and 2019. All patients underwent choledochal cyst excision after ultrasound, CT, or MR cholangiopancreatography. Relevant data including demographics, clinical symptoms, laboratory findings, imaging findings, and outcomes were analyzed. Statistical differences were compared using the Mann-Whitney U test and Fisher's exact test.

RESULTS

Choledochal cyst perforation occurred only in children under the age of 4 years. Acute symptoms, including fever (p < 0.001), were more common in the perforated group than in the non-perforated group. High levels of white blood cells (p = 0.004), C-reactive protein (p < 0.001), and serum amylase (p = 0.002), and low levels of albumin (p < 0.001) were significantly associated with the perforated group. All 14 patients with perforated choledochal cysts had ascites, whereas only 16% (33/204) of patients in the non-perforated group had ascites (p < 0.001). In the subgroup of patients who had ascites, a large amount of ascites (p = 0.001), increase in the amount of ascites in a short time (p < 0.001), complex ascites (p < 0.001), and perihepatic pseudocysts (p < 0.001) were more common in the perforated group than in the non-perforated group.

CONCLUSION

Children with perforated choledochal cysts have characteristic clinical and radiologic findings compared to those with non-perforated choledochal cysts. In young children with choledochal cysts, perforation should be differentiated in cases with acute symptoms, laboratory abnormalities, and characteristic ascites findings.

Ultrasonography in Acute Gallbladder Perforation

The files of patients with acute cholecystitis from two large university hospitals from the years 1978–1985 were employed to find the cases with acute gallbladder perforation for this study. Only those patients (n=9) were selected for the analysis of sonographic signs of acute gallbladder perforation who had less than 48 hours of symptoms before sonography, and were operated upon within 24 hours of the sonography. Patients (n=10) with non-complicated acute cholecystitis and identical in regard to the duration of the symptoms and the timing of the sonography and the operation formed a control group. The sonographic findings in patients with gallbladder perforation were pericholecystic fluid collections, free peritoneal fluid, disappearance of the gallbladder wall echoes, focal highly echogenic areas with acoustic shadows in the gallbladder, and an inhomogeneous, generally echo-poor gallbladder wall.

The CT appearances of gallbladder perforation

Perforation of the gallbladder is an uncommon complication of acute cholecystitis that is associated with relatively high mortality. Symptoms and clinical signs can be indistinguishable from those of uncomplicated acute cholecystitis, leading to delayed diagnosis. We reviewed the clinical and imaging findings in 17 patients with gallbladder perforation confirmed at surgery.

Gallbladder perforation: comparison of US findings with CT

We compared the ultrasound (US) findings of gallbladder (GB) perforation with computed tomography (CT) in 13 patients with GB perforation confirmed at surgery. The common findings of GB perforation were pericholecystic fluid collection and layering of GB wall on US, pericholecystic fluid collection, streaky omentum or mesentery, and GB wall defect on CT. Pericholecystic fluid collection, layering of GB wall, and cholelithiasis were similarly detected on US or CT. GB wall defect and/or bulging of the GB wall suggested a site of perforation was revealed in five patients (38.5%) on US and nine (69.2%) on CT. CT further disclosed the findings of streaky omentum or mesentery (84.6%). CT was superior to US for diagnosis of GB perforation.

Gallbladder perforation: preoperative diagnosis by combined imaging techniques

Gallbladder perforation represents the most serious complication of cholecystitis. Rapid preoperative diagnosis is necessary because of the high morbidity and mortality associated with it. The authors present a case of gallbladder perforation in a 64-year-old man who had been on high doses of steroids. This case was diagnosed preoperatively by combined radiologic imaging methods.

Diagnosis of gallbladder perforation in acute acalculous cholecystitis in critically ill patients

In the presence of ascites ultrasound is not appropriate to distinguish between gallbladder perforation and acute acalculous cholecystitis. However, the correct and early diagnosis of gallbladder perforation is important for the treatment and prognosis. We report 4 critically ill patients with ascites. All patients had evidence of gallbladder perforation by ultrasound and underwent cholecystectomy: 2 patients had gallbladder perforation, but 2 had acalculous cholecystitis without perforation. Markedly elevated serum alkaline phosphatase was the only discriminating finding indicating gallbladder perforation.