2180 Why Is This Hemoperitoneum Orange? A Late Diagnosed Isolated Rupture of the Gallbladder Secondary to Blunt Abdominal Trauma

Abstract

INTRODUCTION: The gallbladder is protected from blunt trauma by its unique anatomic position inferior to the liver and behind the rib cage. Biliary tree injuries are rare, occurring in approximately 2% of cases of blunt trauma. Isolated gallbladder injury is even rarer and the exact incidence is unknown. CASE DESCRIPTION/METHODS: 48 year old male with a history of alcohol abuse who was brought to the Emergency Department with right upper quadrant pain after falling over a fan. Labs showed stable chronic macrocytic anemia and elevated liver function tests. CT revealed ascitic fluid with suspected hemoperitoneum. Surgery managed the patient conservatively in light of stable serial hemoglobin values. Over the next 4 days, the patient developed shock with multi-organ failure. Primary team presumed deteriorating clinical status was related to alcoholic hepatitis and acute on chronic liver failure. Gastroenterology was then consulted and we recommended urgent diagnostic paracentesis. When smeared, the fluid was dark orange in color. A Medicine resident called the GI fellow and asked “why is this hemoperitoneum orange?” Ascitic bilirubin was 25 mg/dL. Surgery believed it was due to hemolysis of the hemoperitoneum. We transferred the patient for urgent ERCP that revealed external accumulation of contrast and bubbles in proximity to the gallbladder. A common bile duct stent was placed. Patient was taken for exploratory laparoscopy where a 5 cm defect on the anterior wall of gallbladder was noted and cholecystectomy was performed. Postoperative course was complicated by a 9 × 7 cm intra abdominal abscess. The collection was not amenable to Interventional Radiology drainage due to its proximity to the spleen. The patient underwent successful endoscopic cystogastrostomy with placement of a lumen apposing metal stent. DISCUSSION: Isolated gallbladder injury remains challenging to diagnose both clinically and radiologically. When suspected, percutaneous drainage is indicated to establish diagnosis even if radiological investigations are unrevealing. There is a high risk of morbidity and mortality secondary to a missed or delayed diagnosis. For patients in whom diagnosis is delayed, abdominal sepsis secondary to non-sterile biliary peritonitis can complicate the postoperative course. ERCP can be performed prior to surgery to reduce the pressure gradient between the biliary system and the duodenum allowing bile to drain preferentially into the duodenum.