1430 Spontaneous Perforation of an Acalculous Hydropic Gallbladder in a Diabetic Patient With Neuropathy: An Under-Diagnosed Entity

Abstract

INTRODUCTION: Gallbladder hydrops (HGB), a gradual increase in volume of the gallbladder in the absence of inflammation or abnormalities of the biliary tract, is under-reported due to various diagnostic criteria used worldwide. The primary cause is cholelithiasis, and initial management is often conservative as they are mostly clinically silent. Surgery is considered for complications of HGB. The universal rise in prevalence of diabetes mellitus (DM) has led to a concomitant increase in the incidence of gallbladder diseases. We report a case of a diabetic patient who presented with viral gastroenteritis and was found to have non-traumatic spontaneous rupture of a HGB. CASE DESCRIPTION/METHODS: 78-year-old male with a complicated cardiac history including heart failure with placement of an automated implanted cardioverter, and non-insulin dependent DM with neuropathy exhibited one-day history of crampy, epigastric abdominal pain with non-bilious, non-bloody vomiting and watery diarrhea. Recently, his grandson was diagnosed with viral gastroenteritis. Patient was afebrile with unremarkable laboratory findings. CT of the abdomen with contrast highlighted a 6.7 cm × 11 cm HGB without cholecystitis or biliary ductal dilatation. Gallbladder ultrasound demonstrated sludge without evidence of wall thickening, gallstones, or pericholecystic fluid. Surgery recommended medical optimization and outpatient cholecystectomy due to his high risk (ASA III). He was admitted for viral gastroenteritis and began IV hydration. Hours later, patient endorsed worsening epigastric pain radiating to the right flank. HIDA scan revealed patency of the cystic duct with evidence of free biliary leak within the right peritoneal cavity. IV antibiotics were initiated followed by emergent cholecystectomy which uncovered a spontaneously perforated gallbladder with ruptured biliary contents into the peritoneum. Later, he developed septic shock, multi-organ failure, and expired on day 6. DISCUSSION: HGB, although rare, is frequent in the DM population and can present with serious complications. Our literature review uncovered that diabetics can develop HGB even in the absence of gallstones. Autonomic dysfunction affecting gallbladder contractility and reduced sensitivity of the gallbladder wall to cholecystokinin are key mechanisms. A sonogram may be used to screen for gallbladder dysfunction in diabetics, and if HGB is identified, we propose prophylactic cholecystectomy at an appropriate moment to significantly reduce morbidity and mortality.