Intrahepatic type II gall bladder perforation by a gall stone in a CAPD patient
© I. Holzapfel Publishers 2011
Received: 5 March 2011
Accepted: 17 March 2011
Published: 12 May 2011
Perforation of the gall bladder represents a rare, but life-threatening complication of cholecystitis. Clinical presentation may vary between severe peritonism in acute perforation and absence of symptoms in subacute or chronic progression of perforation. Abdominal imaging like ultrasound or CT-scan are important tools for immediate diagnose of gall bladder perforation.
We report a case of a 30-year old female patient with end-stage kidney disease treated by continuous ambulatory peritoneal dialysis (CAPD) who was admitted to the emergency room with fever and mild abdominal pain. A type II gall bladder perforation by a solitary gall stone with development of a liver abscess was detected by abdominal ultrasound.
Gall bladder perforations are rare but have to be considered in patients with abdominal pain and fever. Abdominal ultrasound is a reliable tool to establish diagnosis.
A perforation of the gall bladder represents a life-threatening complication of cholecystitis, which occurred in historical study cohorts with an incidence of up to 10-15% [1–3] during acute cholecystitis. The establishment of early cholecystectomy and improvement of antibiotic therapy regimen have reduced the risk of gall bladder perforation in acute cholecystitis to 0.8-3.2% today [4–6].
Gall bladder perforation was classified by Niemeier into three categories . Type I perforation presents as an acute disease with perforation into the free abdominal cavity, whereas type II perforation is characterized as a subacute stage with development of a pericholecystic abscess. Type III perforation arises in chronic cholecystitis with development of bilioenteric fistulae. Especially in chronic cholecystitis diagnosis of a gall bladder perforation may be delayed, when acute symptoms including peritonism are missing . In these cases abdominal imaging by ultrasound or computed tomography is a useful tool.
We report on an oligosymptomatic gall bladder perforation into the liver due to cholecystolithiasis in a patient with peritoneal dialysis.
A perforation of the gall bladder currently arises in 0.8-3.2% of the cases with acute onset of cholecystitis, but there is no data about the incidence of gall bladder perforation in chronic cholecystitis. Most cases present with a rupture into the peritoneal cavity. Development of an intrahepatic abscess represents a rare complication and is reported in literature only by several case reports. Both, perforation of the gall bladder or pyogenic liver abscess represent a life-threatening complication with mortality rates of 7%  and 5.6%  as shown by retrospective studies.
Gall bladder perforation is divided into three categories accordingg to progress (acute - subacute - chronic) and type of perforation (into free abdominal cavity - development of pericystic abscess - development of fistulae). This classification was described first by Niemeier in 1934. With regard to the histologically proven chronic-recurring cholecystitis and the development of an intrahepatic abscess this case has to be classified as a type II perforation. The incidence of clinical symptoms is variable and may be absent in chronic or subacute progression of disease. The performance of an abdominal ultrasound is an essential part of the work up of patients with fever and abdominal pain. In asymptomatic patients or cases with just mild abdominal pain gall bladder perforations may be diagnosed solely by imaging procedures.
Only two studies from 1994 and 2002 with low numbers of patients (combined n = 31) compared diagnostic findings between ultrasound and computed tomography in patients with gall bladder perforation. In comparison to the CT-scan, ultrasound seems to be less sensitive with 70% vs. 80% for the detection of the perforation [10, 11]. Nevertheless, with regard to the improvement of resolution of modern sonographic imaging equipment, better results can be expected today. Therefore, abdominal ultrasound represents a reliable tool as imaging of first choice. CT scans are needed in cases of discrepancies between clinical symptoms and inconspicuous ultrasound as well as for better pre-operative planning subsequently to the sonographically proven perforation. CT scans have the advantage of a better representation of extensive findings because of the bigger field of view (FOV) and may demonstrate the extension of a lesion more clearly.
Patients who need CAPD show a significant higher incidence of peritonitis in comparison to the general population . Nevertheless, there is no evidence in the literature that patients with CAPD show a higher incidence of cholecystitis or risk of gall bladder perforation than the general population even if some studies demonstrate that the prevalence of cholelithiasis may be higher in patients with dialysis than in non-dialysed control groups [13–16]. Analysis of the peritoneal fluid in this patient showed no white blood cells and lack of bacterial growth in culture. Therefore it seems to be unlikely that the peritoneal fluid was the origin for bacterial infection of the gall bladder. The onset of an acute on chronic cholecystitis with the development of a gall bladder perforation represented an independent disease with no relation to the continuous ambulatory peritoneal dialysis.
Interestingly, Murphy's sign as a clinical evidence of peritonism was not detectable. Usually, palpation of the gall bladder is painful when inflamed peritoneal layers rub on each other. However, when free fluid is present - as it is in patients with peritoneal dialysis - peritoneal layers are separated and Murphy's sign may vanish. Secondly, peritoneal layers may not have been affected in this patient because this was a covered perforation into the liver.
In conclusion, the present case shows that life threatening gall bladder ruptures have to be considered in patients with fever and only mild abdominal symptoms. In these patients ultrasound is a reliable tool to diagnose gall bladder perforation and avoids delay of treatment.
- Wallace R, Allen A: Acute cholecystitis. Arch Surg 1943,43(5):762–72.View ArticleGoogle Scholar
- MacDonald JA: Perforation of the gallbladder associated with acute cholecystitis: 8-year review of 20 cases. Ann surg 1966,164(5):849–52. 10.1097/00000658-196611000-00010PubMed CentralPubMedView ArticleGoogle Scholar
- Larmi TK, Kairaluoma MI, Junila J, Laitinen S, Stahlberg M, Fock HG: Perforation of the gallbladder. A retrospective comparative study of cases from 1946–1956 and 1969–1980. Acta Chir Scand 1984,150(7):557–60.PubMedGoogle Scholar
- Stefanidis D, Sirinek KR, Bingener J: Gallbladder perforation: risk factors and outcome. J Surg Res 2006,131(2):204–8. 10.1016/j.jss.2005.11.580PubMedView ArticleGoogle Scholar
- Kiviluoto T, Siren J, Luukkonen P, Kivilaakso E: Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis. Lancet 1998,351(9099):321–5. 10.1016/S0140-6736(97)08447-XPubMedView ArticleGoogle Scholar
- Bedirli A, Sakrak O, Sozuer EM, Kerek M, Guler I: Factors effecting the complications in the natural history of acute cholecystitis. Hepato-gastroenterology 2001,48(41):1275–8.PubMedGoogle Scholar
- Niemeier OW: Acute Free Perforation of the Gall-Bladder. Ann Surg 1934,99(6):922–4.PubMed CentralPubMedView ArticleGoogle Scholar
- Derici H, Kara C, Bozdag AD, Nazli O, Tansug T, Akca E: Diagnosis and treatment of gallbladder perforation. World J" Gastroenterol 2006,12(48):7832–6.PubMed CentralPubMedGoogle Scholar
- Meddings L, Myers RP, Hubbard J, Shaheen AA, Laupland KB, Dixon E, et al.: A population-based study of pyogenic liver abscesses in the United States: incidence, mortality, and temporal trends. Am J Gastroenterol 105(1):117–24.Google Scholar
- Sood BP, Kalra N, Gupta S, Sidhu R, Gulati M, Khandelwal N, et al.: Role of sonography in the diagnosis of gall bladder perforation. J Clin Ultrasound 2002,30(5):270–4. 10.1002/jcu.10071PubMedView ArticleGoogle Scholar
- Kim PN, Lee KS, Kim IY, Bae WK, Lee BH: Gallbladder perforation: comparison of US findings with CT. Abdom Imag 1994,19(3):239–42. 10.1007/BF00203516View ArticleGoogle Scholar
- Davenport A: Peritonitis remains the major clinical complication of peritoneal dialysis: the London, UK, peritonitis audit 2002–2003. Perit Dial Int 2009,29(3):297–302.PubMedGoogle Scholar
- Hojs R: Cholecystolithiasis in patients with end-stage renal disease treated with haemodialysis: a study of prevalence. Am J Nephrol 1995,15(1):15–7. 10.1159/000168796PubMedView ArticleGoogle Scholar
- Hahm JS, Lee HL, Park JY, Eun CS, Han DS, Choi HS: Prevalence of gallstone disease in patients with end-stage renal disease treated with hemodialysis in Korea. Hepato-gastroenterology 2003,50(54):1792–5.PubMedGoogle Scholar
- Gernone G, Detomaso F, La Rosa R, Giannattasio M: [Are dialysis-patients a risk population for cholelithiasis? Study in an apulian population]. Minerva urologica e ne-frologica. Ital J Urol Nephrol 2009,61(1):21–6.Google Scholar
- Badalamenti S, DeFazio C, Castelnovo C, Sangiovanni A, Como G, De Vecchi A, et al.: High prevalence of silent gallstone disease in dialysis patients. Nephron 1994,66(2):225–7. 10.1159/000187805PubMedView ArticleGoogle Scholar