Gallbladder perforation - radiological aspects, types and causes, ultrasound and CT findings

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1 Gallbladder perforation - radiological aspects, types and causes, ultrasound and CT findings Poster No.: C-1905 Congress: ECR 2013 Type: Educational Exhibit Authors: V. Urban, M. Djosev, T. Nastasic, B. Begenisic, N. Terzic, S M. Arsenovic, G. Lukic, D. Lalosevic, M. Stojanovic ; Belgrade/ 2 3 RS, Belgrad/RS, Beograd/RS Keywords: Biliary Tract / Gallbladder, Ultrasound, CT, Diagnostic procedure, Acute DOI: /ecr2013/C-1905 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 37

2 Learning objectives To present ultrasound and CT findings in different types of gallbladder perforation To describe direct and indirect signs of gallbladder perforation To describe radiological findings in gallbladder diseases that carry high risk of perforation Background Perforation is a rare complication of acute cholecystitis and other gallbladder pathology, with an incidence of up to 11%, but with a high mortality rate (up to 60%). Delay in diagnosis is the main cause of lethal outcomes. Signs and symptoms of gallbladder perforation are non-specific and similar to those of uncomplicated acute cholecystitis, and many cases are diagnosed only during surgery. Therefore, proper radiological evaluation is crucial. Although acute cholecystitis is more common in women, gallbladder perforation is more common in men. Gallbladder perforation usually starts with impaction of a bile stone in the cystic duct, followed by gallbladder distension, vascular impairment and ischemia of the gallbladder wall, usually at the fundus, which is the most distal part and therefore poorly vascularised. The ischemic part necrotises and eventually ruptures, sometimes precipitated by infection. Perforation may also follow acalculous cholecystitis, although rarely. Certain gallbladder diseases, such as emphysematous and gangrenous cholecystitis, malignancy and trauma, are especially associated with high risk of perforation. According to the revised Niemeier's classification, there are three types of gallbladder perforation: Type I - acute: free gallbladder perforation and generalised biliary peritonitis - rarest, but with the worst prognosis Type II - subacute: pericholecystic abscess and localised peritonitis - most common Type III - chronic: internal fistula, mostly to the duodenum or common bile duct Page 2 of 37

3 Depending on the perforation site, the clinical course may be different. If the perforation is at the fundus, the bile often drains into the peritoneal space (type I), since the fundus is not always covered by the omentum. Perforation at other sites is often covered by the omentum or intestinal loops and results in pericholecystic fluid collections (type II). Symptoms of type I and type II very much resemble acute uncomplicated cholecystitis. Type III may cause gastrointestinal obstruction (gallstone ileus). While type I and II are usually accompanied by fever and elevated WBC count, type III rarely causes [1] fever and shows only a slight increase in WBC count. Contents of a perforated gallbladder might be contained in the extraperitoneal gallbladder fossa, resulting in [2] delayed onset of symptoms of peritonitis. In some cases, a sudden decrease in pain due to decompression may be a sign of perforation. Also, perforation should be suspected in patients with acute cholecystitis who suddenly become toxic and whose clinical condition [3] starts to deteriorate rapidly. Type I perforation is often associated with atherosclerosis, diabetes, malignancy, cirrhosis and immunosupression, without a history of chronic cholecystitis, while type III [1] perforation usually occurs in patients with long time history of gallstones. Imaging findings OR Procedure details Ultrasound is usually the initial imaging method in radiological evaluation of gallbladder perforation and it yields excellent results. However, intestinal gas and pain may limit its possibilities. CT is the most sensitive imaging method for gallbladder perforation and often follows ultrasound examinations. In gallbladder perforation there are three groups of findings: in the gallbladder itself in structures adjacent to the gallbladder (pericholecystic changes) in other organs. Signs of gallbladder perforation may be direct or indirect. Direct signs of gallbladder perforation are: defect of gallbladder wall ("hole sign" - most specific, but not always visible) gallstones outside the gallbladder (in bowel lumen or peritoneal cavity) Other, non-specific signs are: Page 3 of 37

4 gallbladder distension gallbladder collapse intraluminal membranes coarse intraluminal echogenic debris thickened, irregular, bulging and/or absent gallbladder wall post-contrast enhancement of gallbladder wall (on CT) gas in gallbladder wall or lumen pericholecystic fluid collections pericholecystic abscess pericholecystic fat stranding biloma fistulae bile duct dilatation free intraperitoneal fluid inflammation of pericholecystic liver parenchyma liver abscess pneumobilia portal vein thrombosis thickening of adjacent bowel wall ileus The "hole sign" (Fig. 1 on page 6, Fig. 2 on page 6, Fig. 3 on page 7, Fig. 5 on page 8, Fig. 7 on page 12, Fig. 10 on page 13, Fig. 15 on page 17) is more often visualised on CT than on US. The better the resolution of the ultrasound probe, the higher the chance of visualising the hole. Konno et al. reported two cases where bile leakage through the perforated gallbladder wall was clearly demonstrated by color [4] Doppler US. CT is more accurate in visualising free intraperitoneal fluid, pericholecystic [1] fluid and abscess. All non-specific signs listed above are more or less often found in other gallbladder diseases. However, sudden change in clinical course (relief or worsening of symptoms) of acute cholecystitis followed by changes in radiological findings such as decrease in gallbladder distension, more thickened and/or more irregular gallbladder wall (Fig. 9 on page 11, Fig. 10 on page 13, Fig. 13 on page 16, Fig. 15 on page 17, Fig. 26 on page 26) and formation of pericholecystic (Fig. 1 on page 6, Fig. 2 on page 6 Fig. 4 on page 8 Fig. 6 on page 9, Fig. 13 on page 16, Fig. 14 on page 16, Fig. 15 on page 17, Fig. 21 on page 23 Fig. 22 on page 21, Fig. 26 on page 26, Fig. 27 on page 27) or intraperitoneal fluid collections (Fig. 16 on page 18, Fig. 17 on page 28) are highly suggestive of perforation, even if the perforation site cannot be visualised. Distension of the gallbladder (Fig. 9 on page 11) and oedema of its walls may be [5] the earliest signs of impeding perforation. Signs like pericholecystic fluid collections and free intaperitoneal fluid are rarely found in uncomplicated acute cholecystitis and Page 4 of 37

5 therefore should raise suspicion of perforation in the absence of direct signs. Also, signs of emphysematous or gangrenous cholecystitis increase the risk of perforation. The crumpled wall of a decompressed gallbladder floating within fluid of the gallbladder fossa [2] has a distinctive appearance and can be seen in some cases of type I perforation. [6] Pericholecystic abscesses are classified into three types : Type I - adjacent to the gallbladder (Fig. 3 on page 7) Type II - intramural (Fig. 7 on page 12 Fig. 8 on page 10 Fig. 10 on page 13, Fig. 11 on page 14) Type III - intraperitoneal Inflammation of pericholecystic liver parenchyma (Fig. 18 on page 19, Fig. 19 on page 20) and/or liver abscess (Fig. 12 on page 15) may be signs of an intrahepatic perforation, especially if there is direct continuity with the gallbladder (Fig. 28 on page 29, Fig. 29 on page 30), if the abscess contains stones and there is no pericholecystic fluid. Also, liver abscess with no discernible gallbladder is also highly [7] suggestive of an intrahepatic perforation. Typical of gallbladder perforation with liver abscess formation is a long period of time between onset of symptoms and diagnosis. Signs of a fistula include gas in the gallbladder (Fig. 24 on page 24), bile ducts (Fig. 23 on page 23) and/or gall stones in the bowel (Fig. 25 on page 25), sometimes with signs of bowel obstruction, mostly in the ileum. If the stone obstructs the duodenum, it is called Bouveret syndrome. Fistulae may form between the gallbladder and the duodenum, transverse colon or common bile duct, and sometimes they may be complex. Certain forms of acute cholecystitis, such as gangrenous and emphysematous cholecystitis carry high risk of perforation and should therefore be thorougly investigated. Although it may look very similar to acute uncomplicated cholecystitis, gangrenous cholecystitis more often presents with floating intraluminal membranes (sloughed mucosa, Fig. 30 on page 34), gas within the gallbladder wall or lumen (echogenic foci on US), lack of gallbladder wall enhancement (on CT), mural striation, disruption [8] of the gallbladder wall and/or pericholecystic abscess formation. On US, probably the most specific sign of gangrenous cholecystitis is gallbladder wall striation (alternating [9] mural hyperechoic and hypoechoic linear areas). Emphysematous cholecystitis usually affects elderly men, often with diabetes. Although findings may also be similar to acute uncomplicated cholecystitis, certain signs are suggestive of emphysemaotus change. Characteristic US signs include punctate hyperechoic foci within the gallbladder wall or [10] lumen (Fig. 20 on page 22, Fig. 21 on page 23), often with reverberation artifact, due tu gas collections. CT is the most sensitive and specific imaging technique for the [11] diagnosis of emphysematous cholecystitis. Typical CT findings are low-attenuation foci that represent gas in the gallbladder wall or lumen (Fig. 31 on page 31, Fig. 32 on page 32). Page 5 of 37

6 The gallbladder wall defect may be very small (microperforation) and the corresponding signs very discreet and easily missed. Therefore, small pericholecystic fluid collection, abscesses, wall irregularities or inflammation of adjacent liver parenchyma should raise suspicion of a microperforation (Fig. 33 on page 33). Images for this section: Fig. 1: Patient 1 - Hole sign (red arrow) and pericholecystic fluid (yellow arrow). Page 6 of 37

7 Fig. 2: Patient 1 - Hole sign (B), pericholecystic fluid (C) and gallstone in gallbladder lumen (A). Fig. 3: Patient 2 - Hole sign and small pericholecystic abscess (red arrow). Page 7 of 37

8 Fig. 4: Patient 3 - Pericholecystis fluid (red arrow) and air in the gallbladder lumen (blue arrow). Page 8 of 37

9 Fig. 5: Patient 3 - Hole sign (red arrow) and inflammatory bloc with ascending colon. Page 9 of 37

10 Fig. 6: Patient 3 - Pericholecystic fluid (red arrow). Page 10 of 37

11 Fig. 8: Patient 4 - Inflammatory fat stranding adjacent to the perforation site (red arrow) and fluid collection in the gallbladder wall (green arrow). Page 11 of 37

12 Fig. 9: Patient 4 - Distension of the gallbladder. Page 12 of 37

13 Fig. 7: Patient 4 - Hole sign (red arrow) and fluid collection in the gallbladder wall (green arrow). Page 13 of 37

14 Fig. 10: Patient 5 - Hole sign (red arrow) in an intramural fluid collection; thickened, irregular gallbladder wall (green arrow). Page 14 of 37

15 Fig. 11: Patient 5 - Intramural fluid collections and gallstone in gallbladder lumen. Page 15 of 37

16 Fig. 12: Patient 5 - Liver abscess (red arrow) due to gallbladder perforation. Fig. 13: Patient 6 - Thickened gallbladder wall (red arrow) and pericholecystic fluid collection (green arrow). Page 16 of 37

17 Fig. 14: Patient 6 - Pericholecystic fluid collection and possible hole sign (red arrow). Hydatid cysts in the subdiaphragmatic parts of the liver. Page 17 of 37

18 Fig. 15: Patient 7 - Hole sign (red arrow), small pericholecystic fluid collection (green arrow) and irregular wall (yellow arrow). Page 18 of 37

19 Fig. 16: Patient 7 - Free intraperitoneal fluid. Page 19 of 37

20 Fig. 18: Patient 8 - Distended gallbladder with thinned wall and propagation into adjacent liver parenchyma (possible hole sign). Page 20 of 37

21 Fig. 19: Patient 8 - Distended gallbladder with thinned wall and propagation into adjacent liver parenchyma (possible hole sign). Page 21 of 37

22 Fig. 22: Patient 9 - Emphysematous cholecystitis with perforation. Small pericholecystic fluid collection visible on right image. Page 22 of 37

23 Fig. 20: Patient 9 - Emphysematous cholecystitis with perforation - hyperechoic foci with posterior enhancement - gas in gallbladder wall. Fig. 21: Patient 9 - Emphysematous cholecystitis with perforation - hyperechoic foci with posterior enhancement (gas in gallbladder wall - red arrow) and small pericholecystic fluid collection (green arrow). Page 23 of 37

24 Fig. 23: Patient 10 - Perforation type III - gas in intrahepatic bile ducts. Page 24 of 37

25 Fig. 24: Patient 10 - Perforation type III - air-fludi levels in gallbladder Page 25 of 37

26 Fig. 25: Patient 10 - Perforation type III - gallstone in ascending colon. Page 26 of 37

27 Fig. 26: Patient 11 - Extraluminal gallstone (red arrow), intraluminal gallstone (blue arrow), thickened irregular gallbladder wall (yellow arrow), pericholecystic fluid collections (green arrow). Page 27 of 37

28 Fig. 27: Patient 11 - Pericholecystic fluid collections (red arrow) and inflammatory reaction. Page 28 of 37

29 Fig. 17: Patient 7 - Free intraperitoneal fluid (green arrow) and signs of panniculitis (red arrow). Page 29 of 37

30 Fig. 28: Patient 12 - Intrahepatic abscess following gallbladder perforation - discontinuity of gallbladder wall (red arrow). Page 30 of 37

31 Fig. 29: Patient 12 - Intrahepatic abscess following gallbladder perforation - discontinuity of gallbladder wall (red arrow). Page 31 of 37

32 Fig. 31: Patient 13 - Emphysematous cholecystitis - gas in gallbladder lumen and wall (red arrow). Page 32 of 37

33 Fig. 32: Patient 14 - Emphysematous cholecystitis in an elderly diabetic male patient gas in the wall of distended gallbladder. Page 33 of 37

34 Fig. 33: Patient 16 - Microperforation - discreet linear pericholecystic fluid collection. No hole sign visible. Page 34 of 37

35 Fig. 30: Patient 15 - Gangrenous cholecystitis - sloughed gallbladder mucosa. Page 35 of 37

36 Conclusion Gallbladder perforation is a rare, but potentially life-threatening complication of acute cholecystitis, that poses a great diagnostic challenge. Since a delay in establishing the correct diagnosis is the main cause of mortality, early diagnosis and treatment are of utmost importance. Therefore, it is necessary to know and to thoroughly explore and evaluate US and CT signs that may confirm or suggest gallbladder perforation. References 1. Derici H, Kara C, Bozdag AD, Nazli O, Tansug T, Akca E. Diagnosis and treatment of gallbladder perforation. World J Gastroenterol 2006; 12(48): Morris BS, Balpande PR, Morani AC, Chaudhary RK, Maheshwari M, Raut AA. The CT appearances of gallbladder perforation. British J Radiology; 80 (2007), Gore RM, Ghahremani GG, Joseph AE, Nemcek AA Jr, Marn CS, Vogelzang RL: Acquired malposition of the colon and gallbladder in patients with cirrhosis: CT findings and clinical implications. Radiology 1989, 171: Konno K, Ishida H, Sato M, Naganuma H, Obara K, Andoh H, Watanabe S. gallbladder perforation: color Doppler findings. Abdom Imaging 27:47-50 (2002) 5. Soiva M, Pamilo M, Paivansalo M, Taavitsainen M, Suramo I. Ultrasonography in acute gallbladder perforation. Acta Radiol 1988;29: Chong VH, Lim KS, Mathew VV. Spontaneous gallbladder perforation, pericholecystic abscess and cholecystoduodenal fistula as the first manifestations of gallstone disease. Hepatobiliary Pancreat Dis Int 2009; 8: Chiapponi et al., Acute gallbladder perforation with gallstones spillage in a cirrhotic patient World Journal of Emergency Surgery 2010, 5:11 Page 36 of 37

37 8. Jeffrey RB, Liang FC, Wong W, Callen PW. Gangrenous cholecystitis: diagnosis by ultrasound. Radiology 1983; 148: Teefey SA, Baron RL, Radke HM, Bigler SA. Gangrenous cholecystitis: new observations on sonography. J Ultrasound Med 1991; 134: Smith EA, Dillman JR, Elsayes KM, Menias CO, Bude RO. cross-sectional Imaging of Acute and Chronic Gallbladder Inflammatory Disease. AJR 2009; 192: Gill KS, Chapman AH, Weston MJ. The changing face of emphysematous cholecystitis. Br J Radiol 1997; 70: Personal Information Department of Radiology University Hospital Centre "Dr Dragisa Misovic - Dedinje" Heroja Milana Tepica Beograd Serbia Page 37 of 37