Man With Blunt Abdominal Trauma

Abstract

A 39-year-old man presented to our emergency department with abdominal pain within 1 hour after injury. A piece of wood hit his right hypochondrium when he was cutting wood during landscape gardening. Vital signs were normal. Examination revealed rebound tenderness and guarding to the right hypochondrium. Blood tests showed elevated liver enzyme levels: aspartate aminotransferase 99 U/L and alanine aminotransferase 101 U/L. Other blood test results were normal. Abdominal ultrasonography and contrast-enhanced computed tomography (CT) were performed (Figures 1 and 2).Figure 2Axial image of contrast-enhanced CT on delay phase. White arrow shows fluid collection around the gallbladder, and white arrowhead shows dense fluid within the gallbladder lumen.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Traumatic gallbladder avulsion and perforation. Abdominal ultrasonography showed swelling of the ventral gallbladder wall without Doppler color flow, which suggested that wall thickness was due to trauma rather than inflammation. Contrast-enhanced CT showed gallbladder dislocation, fluid around the gallbladder, and dense fluid within the gallbladder lumen on delay phase. These findings corresponded with gallbladder injury.1Wittenberg A. Minotti A.J. CT diagnosis of traumatic gallbladder injury.AJR Am J Roentgenol. 2005; 185: 1573-1574Crossref PubMed Scopus (27) Google Scholar Urgent laparotomy revealed biliary leakage, separation of the gallbladder from the fossa, and gallbladder perforation; a cholecystectomy was performed (Figure 3). An intra-abdominal drain was placed longer than usual because of the possibility of biloma. He was discharged from our hospital on day 10. Gallbladder injuries occur in less than 2% of blunt abdominal trauma and are classified as contusion, perforation, and avulsion.2Pavlidis T.E. Lalountas M.A. Psarras K. et al.Isolated complete avulsion of the gallbladder (near traumatic cholecystectomy): a case report and review of the literature.J Med Case Rep. 2011; 5: 392Crossref PubMed Scopus (10) Google Scholar Gallbladder avulsion and perforation sometimes cause biliary leakage and bile peritonitis. CT and ultrasonography often contribute to the diagnosis of gallbladder injury. Although there are some reports of gallbladder injury treated with laparoscopic cholecystectomy,3Kohler R. Millin R. Bonner B. et al.Laparoscopic treatment of an isolated gallbladder rupture following blunt abdominal trauma in a schoolboy rugby player.Br J Sports Med. 2002; 36: 378-379Crossref PubMed Scopus (25) Google Scholar gallbladder injuries often complicate intra-abdominal injuries that require surgical intervention.2Pavlidis T.E. Lalountas M.A. Psarras K. et al.Isolated complete avulsion of the gallbladder (near traumatic cholecystectomy): a case report and review of the literature.J Med Case Rep. 2011; 5: 392Crossref PubMed Scopus (10) Google Scholar In such cases, laparotomy is sometimes chosen as the initial treatment.