Formation and rupture of liver hematomas caused by intrahepatic gallbladder perforation: A case report and review of literature.

Introduction Gall bladder perforation is a rare but life threatening complication of acute cholecystitis with or without stones and is associated with increased morbidity and mortality due to late diagnosis. The late diagnosis is attributed to the fact that most of them are present with the same symptoms as in an uncomplicated acute cholecystitis. Most of them are identified and confirmed by laparotomy as preoperative diagnosis is very rare,that is, on computed tomography scan and ultrasound. We are reporting two cases of gall bladder perforation. Case report The first case was a 70-year-old man who was presented to the emergency department with complaints of pain in the abdomen for 7 days and obstipation for 3 days. The second case was a 58-year-old man who was presented to the emergency department with complaints of pain in the abdomen for 1 week and obstipation for 2 days. Conclusion Gall bladder perforation is a fatal and life threatening complication of acute cholecystitis so early diagnosis is the key, as delay will result in the increase of mortality and morbidity.

e20723 Background: Gastrointestinal perforation is one of the most important complications of bevacizumab. In patients with metastatic non-small cell lung cancer, gastrointestinal perforation has been reported with an incidence of less than 1%. Gallbladder perforation in patients receiving bevacizumab is a very rare complication. Methods: A 66-year-old male patient with stage IV lung cancer (adenocarcinoma) admitted to emergency room with the complaints of right upper quadrant abdominal pain, fever, emesis and no bowel movements, seven days after the 3rdcycle of pemetrexed-cisplatin and bevacizumab chemotherapy. CT scan of abdomen showed air images adjacent to the gallbladder suggesting a perforation and an abscess formation of 3.5x3 cm in diameter. The patient underwent surgery. There was a defect of 2 cm in gallbladder wall and there were 4 gallstones inside the gallbladder. Cholecystectomy was performed and the abscess localized between the gallbladder and liver was drained. The pathological examination showed bleeding areas and atrophy in mucosa. No tumor involvement and no microthrombi in microvessels were seen. After recovery, bevacizumab was permanently discontinued. Results: Based on reports from FDA, there are 15 cases of bevacizumab-induced gallbladder perforation, excluding the described case. When the characteristics of the patients are analyzed, it was seen that 75% of gallbladder perforations occurred within the first 6 months of therapy. Most cases were under treatment for gastrointestinal malignancies. Our case is the fifth case with the diagnosis of lung cancer. Although the coexistence of cholelithiasis in other cases is unknown, chronic inflammation in addition to the disruption of vascular regeneration by bevacizumab may increase the risk of gallbladder perforation. Conclusions: Chronic inflammation related to cholelithiasis can be a predisposing factor of bevacizumab-induced gallbladder perforation. Therefore, caution should be exercised when treating these patients with bevacizumab.

Supra‐elevated CA 19‐9 in a benign hepatic cystadenoma

Osteogenesis imperfecta (OI), also known as brittle bone disease, is an inherited connective tissue disorder (CTD) characterized by recurrent fractures, low bone mass, skeletal deformity, and variable short stature. Gallbladder perforation (GBP) is a rare but serious complication of acute cholecystitis, associated with high morbidity and mortality due to diagnostic delays in both calculous and acalculous cases. This case highlights the importance of maintaining a high index of suspicion for spontaneous ischemic GBP in patients with CTDs such as OI Type III. A 20-year-old woman with severe OI type III presented to the emergency department with a two-day history of abdominal pain and distension. Abdominal computed tomography revealed free intraperitoneal air anterior to the liver and adjacent to the falciform ligament, which was suggestive of GBP. No gallstones or sludge were identified within the gallbladder lumen. An emergent open cholecystectomy was performed. Intraoperative findings revealed a concealed perforation at the gallbladder fundus. Due to dense adhesions and the inability to achieve the critical view of safety, a partial cholecystectomy was performed to reduce the risk of biliary and vascular injury. OI poses significant clinical challenges, including abnormal coagulation, airway obstruction, cardiovascular complications, and delayed wound healing. The patient recovered without complications and was discharged on the seventh postoperative day, remaining asymptomatic during the three-month follow-up period. This case demonstrates that GBP, though rare, should be considered a potential complication in patients with CTDs such as OI Type III. Early recognition and appropriate management are crucial for improving clinical outcomes.

Introduction: Gallbladder perforation (GBP) is an uncommon, life-threatening event, most often seen as a complication of acute cholecystitis. Occurrence of GBP in the absence of cholecystitis is exceedingly rare, but may occur in those with cholelithiasis. We report a case of spontaneous GBP without cholecystitis presenting as painless hemoperitoneum and methicillin-resistant Staphylococcal aureus (MRSA) bacterascites in a patient with decompensated cirrhosis. Case Description/Methods: A 63 year old female with past history of NASH cirrhosis (MELD 27, Child-Pugh C), esophageal varices, and ascites requiring weekly therapeutic paracentesis presented with encephalopathy. A paracentesis on admission was negative for spontaneous bacterial peritonitis by cell count and culture. CT imaging on admission revealed a partial small bowel obstruction (pSBO) and cholelithiasis with an otherwise normal gallbladder and biliary tree. The pSBO resolved with conservative management. One week into the hospitalization, her ascites worsened. A second paracentesis showed 253,290 RBC/mm3, with a corrected ANC of -54 cells/mm3. A 3 gram serum hemoglobin drop was also noted. A repeat abdominal CT scan showed a non-inflamed gallbladder with her known gallstones now layering in the pelvis, suggestive of GBP (Figure). She was initially started on piperacillin-tazobactam, but her ascitic fluid culture later grew MRSA. Based on her surgical risk and overall clinical stability, she was managed non-operatively. She was transitioned to indefinite therapy with amoxicillin-clavulanate and doxycycline, and later discharged home. Discussion: Most GBPs are due to severe inflammation or trauma. Risk factors for spontaneous GBP include cholelithiasis, congenital obstruction, and anticoagulant therapy. Although rare, patients with cirrhosis may have a higher risk for GBP due to venous congestion from portal hypertension and their propensity for cholelithiasis. Her MRSA bacterascites may have been from iatrogenic seeding during the first paracentesis, but the timeline to discovery raised concerns that it originated from the GBP. MRSA is rarely a biliary pathogen, but may result from bacteremia that seeds the gallbladder. Regardless, the patient began indefinite antibiotic therapy, as her gallstones posed as persistent nidi for infection. This case highlights the rare possibility of silent GBP as a cause for worsening ascites, as well as the therapeutic dilemma of retained peritoneal gallstones in a poor surgical candidate.Figure 1.: Gallstones residing in intact gallbladder on left, compared to subsequent scan on the right demonstrating gallstones in patient's pelvis.

Spontaneous acalculous gallbladder perforation mimicking duodenal stump leak after gastrectomy for gastric cancer: A case report.

Gallbladder perforation (GBP) represents a rare, but potentially life-threatening, complication of acute cholecystitis. GBP is subdivided into three categories whereas the development of biloma is extremely rare. The present case study reports on a 40-year-old man with a 10-year history of calculus cholecystitis, who was referred to The First Affiliated Hospital of Nanjing Medical University (Nanjing, China) for the surgical treatment of an emerging massive hepatic entity with insidious symptoms and normal laboratory tests. A preoperative imaging study demonstrated the collection with internal septations and mural nodules, but no visible communication with the biliary system. Given the suspected biliary cystic tumor, a laparotomy was performed and the lumen was scattered with papillae. An intraoperative frozen section examination illustrated a simple hepatic cyst. Biochemical analysis of the collection and histopathology of the gallbladder and capsule substantiated the diagnosis of biloma formation due to GBP. The purpose of the present case report was to demonstrate how a pinhole-sized perforation with extravasation of unconcentrated bile from the gallbladder may result in insidious clinical presentation and an undetected leak site. According to the clinicopathological characteristics and composition, formation of biloma should be classified as type IV GBP. To differentiate bilomas with intracystic septations and mural nodules from BCTs is difficult via a preoperative examination, and the definitive diagnosis should be based on a histological examination. Laparotomy with frozen section examination may be the optimal approach in such a case.

BackgroundSubcapsular hematoma of the liver is a potentially life-threatening but extremely rare condition. It is often caused by a blunt trauma or other predisposing conditions such as a liver tumor, intra-tumor hemorrhage, surgery, preeclampsia, liver biopsy, and hemodialysis. Predisposing causes of liver hematoma include its large size and proximity to fixed structures. To date, there have been no reported cases of subcapsular liver hematoma caused by tight clothing such as corsets. Our case report is about an extremely rare case of subcapsular hematoma of the liver caused by wearing a tight faja corset in a young healthy female.Case presentationA forty-five-year-old Spanish female without any underlying health problems presented with sudden onset epigastric and right upper quadrant abdominal pain after wearing a faja corset the night prior to the hospital presentation. CT abdomen was noted for subcapsular hematoma of the liver. Her symptoms persisted and repeat CT abdomen showing worsening of the liver hematoma. Patient had interventional radiology (IR) guided drainage and was subsequently discharged home.ConclusionsSubscapular liver hematomas need to be considered in patients presenting with acute onset abdominal pain after wearing certain tight clothing. The necessity of an early and accurate diagnosis is vital for management as hemodynamically stable patients can be managed conservatively. Our patient was managed with IR-guided aspiration drainage of the hematoma. Surgery can be considered a last resort in case of life-threatening hemodynamic instability, peritoneal signs, free abdominal fluid, and failure of arterial embolization. Our case highlights the importance of early recognition of traumatic subcapsular hematomas to prevent life-threatening complications.

We present a case of a 35-year-old Ethiopian female patient presented with right upper quadrant abdominal pain. Studies suspected gallbladder disease, for which she operated. Intraoperatively, gallbladder perforation with choledochogastric fistula was identified, with Ascaris lumbricoides (AL) worm in the common bile duct. Cholecystectomy was performed; common bile was repaired with T-tube and gastric repair. Patient was discharged 11 days after. On subsequent follow-up at the surgical referral clinic, the patient had no complaints.

A 66-year-old female has a medical history of remote subarachnoid hemorrhage and dysphagia. She presented with acute onset of right upper quadrant abdominal pain. Ultrasound showed acute cholecystitis, and subsequent CT scan of the abdomen and pelvis showed gallbladder perforation. The patient’s hospital course was complicated with peritonitis, and bile culture grew vancomycin-resistant Lactobacillus paracasei. This case report will focus on an unusual case, in which Lactobacillus acts as the primary pathogen in peritonitis secondary to an cholecystitis-induced gallbladder perforation. There are four other case reports worldwide that illustrate Lactobacillus species as the primary pathogen in cholecystitis, only one of which was complicated with peritonitis.

Introduction: Gallbladder Perforation (GBP) is one of the most dangerous consequences of acute cholecystitis. It presents in a variety of ways, leading to diagnostic dilemmas and posing management challenges. There is high morbidity and mortality associated with this condition and management is not always straightforward in most cases. Aim: To compare clinical presentation, associated co-morbidities and outcomes in ultrasound-guided open/percutaneous drainage followed by delayed cholecystectomy (DC-PCO group) and early laparoscopic/conversion to open cholecystectomy (EC group) for GBP. Materials and Methods: The present study was a retrospective observational study in which case records of 2,366 patients over the last four years (from January 2019 to January 2023) with symptomatic cholecystitis were analysed at a tertiary care centre. A total of 44 adult patients aged over 14 years who had symptomatic cholecystitis on presentation and underwent cholecystectomy due to preoperative diagnosis of GBP were included. Patients with intraoperative findings of GBP, GBP secondary to abdominal trauma and perforation due to gallbladder malignancy were excluded. These 44 patients were classified into two groups. The first group included 24 patients who underwent ultrasound-guided open/percutaneous drainage followed by delayed cholecystectomy, termed the DC-PCO group. The second group included 20 patients who underwent early laparoscopic/conversion to open cholecystectomy, termed the early cholecystectomy group (EC). Demographic profile, morbidities and postoperative outcomes were studied in both groups and the significance of differences was analysed using the Mann-Whitney U test and the Chi-square test. Result: The median age was 49 (25-75) years, with a significantly higher proportion of females compared to males. An 86.4% of patients presented with abdominal pain as the most common complaint (38/44). According to Niemeier’s classification, 13 patients had Type I, 27 patients had Type II and four patients had Type III perforation. The median duration of hospital stay was longer for the EC group compared to the DC-PCO group (p-value=0.028). Additionally, 75% of patients in the EC group had a proximal site of GBP (70% body and 5% neck), while 62.5% of patients in the DC-PCO group had fundus perforation (distal location). This suggests that the more proximal the site of perforation, the denser the adhesions, leading to more difficult dissection and increased perioperative complications (such as CBD injury). Conclusion: The GBP is a serious complication of acute cholecystitis. Management in cases of GBP depends on the clinical condition of the patient, associated co-morbidities, type of GBP and imaging findings. The management revolves around the key decision of initial image-guided drainage versus early exploration. Early cholecystectomy is warranted for frank peritonitis, with the open procedure performed when dense adhesions complicate dissection and the risk of CBD injury is high.

Gall bladder perforation is a serious complication of acute cholecystitis. The purpose of the present study is to evaluate the presenting symptoms, diagnosis and management of patients with gall bladder perforations. A retrospective study was undertaken of 31 consecutive patients with gall bladder perforation in a single unit of a tertiary referral hospital, between January 1996 and December 2001. The incidence of gall bladder perforation was 5.9% of all cases of acute cholecystitis. Associated comorbidity was quite common (58%). Ultrasound and computed tomography scans of the abdomen are sensitive investigations. Ultrasound guided percutaneous drainage helps in tiding over the emergency. The morbidity (35%) and mortality (9.6%) is considerable. The patterns of presentations, diagnosis and management of gall bladder perforation are changing. But there is scope for improvement.

Gallbladder perforation: Case series and systematic review

Gallbladder perforation is an almost exclusive complication of cholecystitis, which accompanies severe inflammation of the gallbladder with or without cholelithiasis. Whether it is of a calculous or acalculous origin, gallbladder perforation, as a complication of acute cholecystitis, has common symptoms, signs, laboratory data, radiological findings and treatment modalities. Even though many reports of gallbladder perforation have been published, there are few reports of gallbladder perforation without any clinical and radiological indications. We experienced a case of a 70-year-old woman with acute abdomen, which was found to be peritonitis caused by spontaneous gallbladder perforation that was devoid of clues suggesting this condition. Although rare and unusual, this case shows that this disorder should be considered in elderly patients presenting with peritonitis with an unknown etiology.

Gallstone Liver Abscess Secondary to Gallbladder Perforation