Abdominal Imaging. Gallbladder perforation: color Doppler findings

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1 Abdom Imaging 27:47 50 (2002) DOI: /s Abdominal Imaging Springer-Verlag New York Inc Gallbladder perforation: color Doppler findings K. Konno, 1 H. Ishida, 1 M. Sato, 1 H. Naganuma, 1 K. Obara, 1 H. Andoh, 2 S. Watanabe 1 1 First Department of Internal Medicine, Akita University School of Medicine, Hondo, Akita, Japan 2 First Department of Surgery, Akita University School of Medicine, Hondo, Akita, Japan Received: 20 February 2001/Accepted: 21 March 2001 Abstract Gallbladder (GB) perforation is a life-threatening complication of acute cholecystitis, and early diagnosis prevents delay in patient management. We present two cases of GB perforation diagnosed by color Doppler ultrasonography. Each clearly showed a flow signal passing through the perforated site, leading to prompt and successful surgical treatment. This interesting observation suggests that color Doppler ultrasonography is useful in the diagnosis of GB perforation. Key words: Gallbladder Ultrasound Doppler Cholecystitis Perforation. Gallbladder (GB) perforation is a life-threatening complication of acute cholecystitis [1 3]. Its clinical and radiologic findings have been reported, but it is usually difficult to differentiate between GB perforation and uncomplicated acute cholcystitis [1 3]. Sonography (US) has become the method of choice for diagnosing GB diseases, and some US findings of GB perforation have been reported, including thickening or bulging of the GB wall and pericystic fluid collection [4 6], but those are nonspecific and some simple and direct US signs of GB perforation have been sought. We present two cases of surgically proven GB perforation in which color Doppler US clearly showed the perforation sites, leading directly to the diagnosis and early successful surgical treatment. To the best of our knowledge, this is the first report describing the usefulness of color Doppler US in the diagnosis of GB perforation. Correspondence to: K. Konno Case reports Case 1 A 60-year-old man visited our hospital with a complaint of mild right upper quadrant discomfort of 3 days duration. Both legs had been amputated because of a traffic accident. He had not received a health checkup during the past 10 years, but he appeared healthy. On physical examination, he was found to be afebrile and normotensive without peritoneal signs. His abdomen was soft and nondistended. The right upper quadrant was mildly tender. Admission laboratory data showed a white blood cell count of 8300/L, mild hepatic dysfunction (aspartate aminotransferase, 52 U/L; alanine aminotransferase, 75 U/L; alkaline phosphatase, 529 U/L), a serum glucose of 486 mg/dl, and hemoglobin A 1c of 11.5%. US showed the GB as extended (12 cm in the long axis) with small stones and the wall thickened (7 mm). The patient s oral intake was stopped, and he was treated for uncontrolled diabetes with intravenous fluids and regular insulin, resulting in rapid normalization of serum glucose levels (97 mg/dl on 3 days after admission). After admission his symptoms progressed slightly and were accompanied by anorexia and a mild fever, but his abdominal symptoms suddenly improved 4 days later. Repeat US showed that the GB was less extended (8 cm in the long axis) with thicker walls (13 mm) than before (Fig. 1A). Pooling of fluid also was seen around the GB fundus, and part of the fundus was obscured (Fig. 1A). Color Doppler US showed normal blood flow in the liver, but it demonstrated a very clear to-and-fro flow signal passing through the fundal wall (Fig. 1B). CT showed pooling of fluid around the GB but not a GB perforation (Fig. 1C). Although his clinical presentation was mild, we suspected a GB perforation on the basis of the color Doppler results. An open cholecystectomy was performed without complications, although complete total excision of the GB was not performed

2 48 K. Konno et al.: Gallbladder perforation Fig. 1. Case 1. A case of GB perforation (fundal wall perforation). A US shows a gallbladder with a very thickened wall containing small stones. Part of the wall is obscured. B Color Doppler US clearly shows a to-and-fro flow signal passing through the wall. C CT shows pooling of fluid collection around the gallbladder, but no perforation is seen of the gallbladder. A perihepatic abscess, G gallbladder, L liver. because of its adhesion to the liver. The fundal wall of the GB was perforated (5 mm in diameter) and communicated with the perihepatic abscess. Multiple small stones were found in the abscess cavity. The pathology showed acute and chronic cholecystitis. Bile in the GB contained innumerable red and white blood cells. The postoperative course was uneventful and the patient was discharged on postoperative day 10. Case 2 A 57-year-old man was admitted to our hospital with rapidly appearing right upper quadrant pain and a mild fever. He had a medical history of well-controlled diabetes mellitus and hypertension. Biochemical data on admission showed a white blood cell count of 12,000/L and mild hepatic dysfunction. US showed a wall-thickened (8 mm) GB containing stones and a focal hypoechoic lesion in the right anterior segment (Fig. 2A). The relation between the hepatic lesion and the GB was undetermined. Color Doppler US after US showed a very clear to-andfro flow signal passing through the GB body wall to the hepatic lesion (Fig. 2B). CT did not show a communication between the GB and the hepatic lesion; however, color Doppler US results led to the diagnosis of liver abscess extending from a perforated GB. The patient underwent US-guided percutaneous abscess and GB drainage, which confirmed our diagnosis. Microscopic evaluation showed innumerable red and white blood cells, and culture of the drained fluid demonstrated Escherichia coli. Open cholecystectomy was performed without complications. The pathology showed acute and chronic cholecystitis. The postoperative course was uneventful and the patient was discharged on postoperative day 21. Discussion Acute cholecystitis, calculous or acalculous, can result in GB perforation in 6 12% of cases [1, 2]. The reported

3 K. Konno et al.: Gallbladder perforation 49 Fig. 2. Case 2. A case of gallbladder perforation (body wall perforation). A US of the liver and gallbladder shows that the gallbladder has a thick wall containing gallstones and liver mass. B Color Doppler US clearly shows a to-and-fro flow signal passing through the body wall. C Percutaneous US-guided cholangiography confirms a communication (arrow) between the gallbladder and the abscess. A perihepatic abscess, G gallbladder, L liver. pathomechanism of GB perforation is considered to be GB distention due to impaction of a calculus in the cystic duct, followed by secondary vascular impairment and ischemia of the GB wall [1, 2]. As a result, the fundus, which is the least well-vascularized part of the GB, is the most common site of perforation [1 3], as was seen in our case1. Although less frequent, GB perforation into the liver, with liver abscess formation, has been reported [5, 6], as was seen in our case 2. Many clinical studies have reported a high incidence of GB perforation after acute cholecystitis, leading frequently to peritonitis and sepsis in diabetic patients [7], and its mortality rate is closely related to delay in diagnosis [1 3]. Thus, early diagnosis of GB perforation is absolutely necessary, especially in diabetic patients. The presenting symptoms are thought to depend on the severity of inflammation and the location and size of the perforation. Symptoms include nausea, upper abdominal pain, vomiting, and fever, but initially they are usually very vague and indistinguishable from those of uncomplicated acute cholecystitis [1, 2]. There frequently is a diagnostic dilemma, and US is expected to contribute to an early and correct diagnosis. Moreover, a GB perforation occurs without severe symptoms in diabetic patients [1 3, 5, 6]. Thus, in a clinical setting, the diagnosis should be prompt and correct especially in diabetic patients. The reported US findings of GB perforation are pericholecystic fluid collection with thickening, bulging, and layering of the GB wall [4 6]. However, those findings are nonspecific and rarely contribute to the differentiation between GB perforation and uncomplicated acute cholecystitis. In 1988, Chau et al. reported an interesting direct US sign of GB perforation, which they called the hole sign on the basis of US findings encountered in GB perforation patients and its resemblance to a hole in a perforated balloon [8]. However, as was reported in another series, that US sign is now believed to occur rarely in GB perforation [4]. After the introduction of color Doppler US in abdominal diagnosis, it was used for a wide range of GB diseases [9, 10]. However, to the best of our knowledge, there have been no data in the literature on color Doppler US findings of GB perforation. In our two cases, bile leakage through the perforated GB wall was clearly demonstrated by color Doppler US. We offer a possible explanation for this phenomenon. In Doppler examinations, red blood cells flowing in the vessels usually scatter US beams, giving rise to echo signals, and because blood cells move, they give rise to Doppler signals [11]. However, theoretically, any moving reflectors give rise to Doppler signals. In our cases, a large number of red and white blood cells in the bile passing through the perforated site was considered to give rise to Doppler signals. Although an analysis of similar cases is absolutely necessary to draw a definitive conclusion, our observation suggests a new way to use color Doppler US. Once GB perforation is diagnosed, an early cholecystectomy should be performed to prevent sepsis [12]. In our two cases, relatively early diagnoses allowed for successful cholecystectomies and favorable prognoses. A high index of suspicion of GB perforation is required in patients with acute cholecystitis, especially in those with diabetes mellitus. A good understanding of the color Doppler findings and appropriate management are needed to reduce serious morbidity and mortality from GB perforation.

4 50 K. Konno et al.: Gallbladder perforation References 1. Sherlock S, Dooley J. Gallstones and inflammatory gallbladder diseases. In:Sherlock S, Dooley J, eds. Diseases of the liver and biliary system. London: Blackwell Scientific, 1997: Stransberg SM, Clavien PA. Acute calculous cholecystitis. In: Haubrich W, Schaffner F, eds. Gastroenterology. Philadelphia: WB Saunders, 1995: Stransberg SM, Clavien PA. Acute acalculous cholecystitis. In: Haubrich W, Schaffner F, eds. Gastroenterology. Philadelphia: WB Saunders, 1995: Kim PN, Lee KS, Kim IY, et al. Gallbladder perforation: comparison of US findings with CT. Abdom Imaging 1994;19: Forbes LE, Bajaj M, McGinn T, et al. Perihepatic abscess formation in diabetes: a complication of silent stones. Am J Gastroenterol 1996;91: Bakalakos EA, Melvin WS, Kirkpatrick R. Liver abscess secondary to intrahepatic perforation of the gallbladder, presenting as a liver mass. Am J Gastroenterol 1996;91: Ikard RW. Gallstones, cholelithiasis and diabetes surgery. Gynecol Obstet 1990;171: Chau WK, Na AT, Feng TT, et al. Ultrasound diagnosis of perforation of the gallbladder: real time application and the demonstration of a new sonographic sign. J Clin Ultrasound 1988;16: Jeffrey RB Jr, Nin-Marcia M, Ralls PW, et al. Color Doppler sonography of the cystic artery: comparison of normal controls and patients with acute cholecystitis. J Ultrasound Med 1995;14: Komatsuda T, Ishida H, Konno K, et al. Gallbladder carcinoma: color Doppler sonography. Abdom Imaging 2000;25: Zagzebski JA. Doppler instrumentation. In: Zagzebski JA, ed. Essentials of ultrasound physics. St Louis: Mosby, 1995: Sianesi M, Ghirarduzzi A, Percudani M, et al. Cholecystectomy for acute cholecystitis: timing of operation, bacteriologic aspects and post-operative course. Am J Surg 1984;148:

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