Perforation of the gallbladder: A frequently mismanaged condition

Abstract

Gallbladder perforation is a lethal complication of cholecystitis, a relatively common disease, and has a mortality of 15 to 20 per cent. At UCLA Hospital seventeen patients with perforation of the gallbladder were evaluated and compared with patients who had previously been reported in the English literature. The purpose of this report was to: (1) establish a set of criteria to identify the patient who is at high risk for gallbladder perforation; (2) detail an appropriate course of diagnostic and therapeutic management; and (3) propose a unified concept of the pathogenesis of gallbladder perforation. The majority of patients were elderly men (mean age, 61 years) and women (mean age, 67 years) with significant atherosclerotic cardiovascular disease or underlying malignancy. Another important subset of patients consisted of young men who were receiving long-term steroid or immunosuppressive therapy for collagen vascular disease. Almost all of the patients with gallbladder perforation were subjected to an inordinate delay in diagnosis and surgical intervention (6.8 days), and this was responsible for a significant complication rate of 58 per cent as well as an extended postoperative hospitalization time (16 days). The mortality for the entire series was 17 per cent. The successful management of gallbladder perforation is based on early recognition of the patients who are at high risk for this condition. Preoperative diagnostic and therapeutic measures can usually be performed within 12 hours and should include ultrasonography or intravenous cholangiography, fluid resuscitation, nasogastric decompression, and broad spectrum antibiotic administration. A successful outcome in these patients, however, can be achieved only with operative intervention.