Gallbladder Perforation.

Correlation of CT findings with the

Niemeier classification.

Poster No.: C-1819

Congress: ECR 2015
Type: Educational Exhibit
Authors: V. Papalouka, V. Bizimi, C. Kontopoulou, V. Mellou, S. Grigoriadis,
A. Kalpaxi, K. Spyrou; Athens/GR
Keywords: Inflammation, Acute, Abscess, Staging, Diagnostic procedure,
Ultrasound, CT, Biliary Tract / Gallbladder, Abdomen
DOI: 10.1594/ecr2015/C-1819

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Learning objectives

To review the clinical and imaging findings of gallbladder perforation (GBP).

To present the types of GBP using CT scan images and collerate imaging
findings with Niemeier's classification.
To present our experience in 26 patients.

Background

Gallbladder perforation (GBP) stands for the development of a hole or a rapture of

the gallbladder wall and is a rare complication associated with high morbidity and
mortality. It often occurs as a result of acute cholecystitis, either during the acute phase
of inflammation or in a delayed phase- several days after the onset o cholecystitis.
1
GBP may rarely develop secondary to acalculous cholecystitis. Others predisposing -
causative factors have also been reported, such as diabetes mellitus, atherosclerotic
2
cardiovascular disease, immunosuppression and AIDS in younger population. Although
acute uncomplicated cholecystitis is more common among females, with a female to male
3, 4
ratio of 2:1, GBP is more frequent in male gender.

Page 2 of 13
Fig. 1: Schematic anatomy of the gallbladder.
References: http://en.wikipedia.org/wiki/Gallbladder

Pathophysiology:

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The pathogenesis of GBP is based on the aggravation of the gallbladder inflammation
which may cause ischemia and necrosis, thus resulting to a perforation. This may occur
in 2% to 11% of acute cholecystitis patients. GB fundus is considered the most vulnerable
2,
and commonest site of perforation, due to its distal location and its limited blood supply.
5
When the perforation occurs at the fundus the bile and stones drains into the peritoneal
space, since the fundus is less covered by the omentum. If the leak presents in a different
site of the GB wall, it is usually covered by the omentum or the intestines and limited in
6
the right upper quadrant forming a plastrone, pericholecystic fluid or an abscess.

Page 4 of 13
Page 5 of 13
Fig. 2: GB perforation.
References: http://www.wikidoc.org/index.php/
Gallstone_disease_natural_history,_complications_and_prognosis.

Clinical presentation:

Clinical manifestations of GBP are multifarious, while there is a considerable difficulty

to discriminate clinically patients with uncomplicated acute cholecystitis and those with
perforated gallbladder. Presenting symptoms are usually atypical, ranging from mild
upper right quadrant abdominal pain to clinical picture of peritonitis. Patients may also
present with symptoms mimicking malignancy, such as malaise, and weakness or
with persisting high fever. Therefore, a sudden deterioration of the clinical status of a
patient with acute cholecystitis, should be considered highly suspicious for gallbladder
perforation. Additionally, several systemic diseases need to be taken into account, such
as diabetes mellitus, which contributes to the emergence of this complication and at the
6
same time may obscure patient's clinical status.

Based on the above, GBP diagnosis is often challenging and cross- sectional imaging
should be applied in any suspicious case. Amongst other imaging modalities, CT is
considered the method of choice, offering characteristic appearances of this problem.

Findings and procedure details

7
Neimeier (1934) first proposed a classification of gallbladder perforation. According to
him there are three categories of GBP:

Type I: comprise acute free perforation into the peritoneal cavity.

Type II: involves patients with subacute - localized perforation with
pericholecystic abscess.
Type III: is characterized with chronic perforation, with cholecysto-enteric
fistulas.

Additional forms of type III were reported in the known literature, including
8
cholecystobiliary fistula and more complex fistula formations and cases of intrahepatic
9
perforation of the gallbladder with liver abscess and cholecystohepatic communication.

Several modified classifications have been propose since then, but the basic
8, 10
classification of Neimeier still remains the gold standard.

Procedures and Findings:

Page 6 of 13
 A retrospective study of a 64-sliced CT scans of the abdomen performed on
26 patients with gallbladder perforation.
All patients suffered from acutecholecystitis, not clinically improved with the
conservative treatment.
CT findings were graded based onNeimeier's classification.

According to this :

Type I in 3 patient. (Figure 3)

Type II in 17 patients. (Figure 4, 5, 7, 8)

Type III in 6 patients. (Figure 6)

The site of perforation was single in the majority of cases, located at the
fundus of the gallbladder.
Gallstones were visible in 88.5% of cases.
The diagnosis of GBP was confirmed at surgery in all patients.

6
CT findings suggestive of GBP includes:

1. GB wall defect. (Most direct sign of perforation).

2. GB wall thickening and enhancement and/or mural hemorrhage.
3. Intramural abscess and/or gas.
4. Intraluminal membranes and/or gas.
5. Gallstones. Common bile duct or cystic duct stones or Mirizzi syndrome .
10

6. Pericholecystic changes including: Fat stranding / Fluid collection /

Abscess /Biloma.
7. Extraluminal stones (intraperitoneal).
8. Liver involvement: Pericholecystic liver enhancement / Abscess / Portal vein
thrombosis.
9. Wall thickening of adjacent gastrointestinal tract.
10. Cholecysto-enteric fistulas.
11. Reactive regional lymph nodes.
12. Intraperitoneal free fluid-ascites and/or air.
13. Ileus .

Images for this section:

Page 7 of 13
Fig. 3: CT images of a patient diagnosed with Type I GBP secondary to acute
cholecystitis. CT illustrates GB mural thickening and heterogeneous enhancement, with
focal wall defects (red arrow). There is also pericholecystic fluid collection.

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Fig. 4: Type II GBP. CT images show a well defined abscess formation in the
pericholecystic region (yellow arrow) with thick intraluminal membranes (green arrows).
Bilateral pleural effusions are noted. The findings are indirect signs highly suspicious for
local sealed GBP. The diagnosis was confirmed at the surgery.

Fig. 5: CT images (coronal- left and axial- middle and right) of a patient with Type II
GBP. An enlarged GB is noted, with wall thickening and enchancement and mural defect
at the anterolateral aspect of the GB wall (yellow arrows). A 68mm hypodense lesion
with rim enchancement at S6 of the liver, is also shown (red circle). These findings were
suggestive of suppurative cholecystitis with intrahepatic perforation and liver abscess
formation.

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Fig. 6: A patient with chronic presentation of GBP- Type III. CT images shows intraluminal
gas and a well defined fluid collection with gas adjacent to the GB fundus. There is a
communication between the GB lumen and the descending part of the duodenum (DD),
consistent with cholecysto-enteric fistula (yellow arrows).

Fig. 7: A patient with a history of AML presented with Type II GBP. CT images show
mural thickening and edema with multiple microdefects of the GB wall. There are also
intramural abscesses (red arrow) and evidence of pericholecystic inflammation with fat
stranding, fluid collection and abscess. A gallstone is lying at the GB neck (yellow circle).

Fig. 8: An 80 year old woman presented with high fever and right upper abdominal
pain. Initial ultrasound imaging findings included sonographic Murphy sign, gallbladder
wall thickening and pericholecystic fluid collection (images not shown). Since, clinical
symptoms persisted and the patient became septic, a CT scan after IV administration

Page 10 of 13
of contrast medium was obtained. CT images on axial (left) and coronal (right) plane
illustrate: gallbladder wall defect to the liver with a large collection of fluid with rim
enhancement in S4 & S5 sections of the liver, consistent with abscess. Type II GBP.

Page 11 of 13
Conclusion

Diagnosis of gallbladder perforation in the setting of inflammation is usually challenging

for the clinicians since clinical signs and symptoms are usually unclear or obscured. It
is therefore, crucial to be promptly identified and treated. CT has been proved to be
the modality of choice in the early diagnosis of this fatal complication, aiding in both
the diagnosis and the classification of GBP and contributing to an early and targeted
therapeutic approach.

Personal information

Dr Vasiliki Papalouka

2nd department of Radiology, University hospital of Athens " ATTIKON", Athens/ GR.

email: vasiliki_papa@hotmail.com

References

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9. Bakalakos EA, Melvin WS, Kirkpatrick R: Liver abscess secondary to
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