Dados do Trabalho

Título

Non-traumatic gallbladder perforation with sludge extravasation complicated with hepatic abscess: a case report

Introdução

Gallbladder perforation (GBP) is a rare but life-threatening complication of acute cholecystitis with high morbidity and mortality rates because of delay in diagnosis. In the present study, we report a case of GBP in a patient with minor clinical symptoms that presented ultrasonography findings of cholelithiasis with GBP and sludge extravasation.

Descrição

A 93-year-old male patient presented to the emergency department with 24 hours onset of one episode of compressive abdominal pain of moderate intensity in the right upper quadrant referring just one similar episode in the last 15 days.
An abdomen sonography was performed in supine, left posterior oblique, and left lateral decubitus positions using the intercostal and subcostal approaches. Sonography presented a gallbladder (GB) containing impacted sludge, several calculi, and an image suggestive of GB perforation of the posterior wall (curved arrows), with a localized collection of fluid (straight arrows). A computed tomography (CT) scan was then performed with axial and coronal reconstructions showing a hyper attenuation into the GB with a defect in the wall (curved arrow) and a small pericholecystic fluid collection (straight arrow) in the same topography observed in sonography.
A laparoscopic cholecystectomy was performed 48 hours after the initial sonographic examination and revealed a perforation of the posterior wall of the GB, with local necrosis and abscess formation to the liver posteriorly to the gallbladder (empyema with liver abscess).

Discussão

Although perforation of the gallbladder is not a frequent complication of acute cholecystitis, the mortality rate associated with perforation is as high as 24%. Therefore, imaging has an important role in early diagnosis.
Distended GB; a thickened, edematous gallbladder wall; pericholecystic fluid; cholelithiasis; and bulging of the GB wall have been described as nonspecific findings. The sonographic hole sign, in which the defect in the GB wall is visualized, is the only reliable sign of GBP. Despite GBP is easily observed on CT scans, in nonobese patients, even small fluid collections can be sonographically visualized, and a diagnosis of GBP might be possible.
We conclude that although CT plays an important role in diagnosing gallbladder perforation, the utility of sonography should not be underestimated. If sonography is performed using proper technique, the defect in the gallbladder wall due to perforation can be accurately diagnosed.

Palavras Chave

gallbladder perforation, abdomen sonography, abdominal sepsis, sludge extravasation, hepatic abscess