Gallbladder perforation causing local peritonitis in left upper abdomen: A case report

Abstract

Introduction and importance: Type 1 gallbladder perforation (GBP) in the free abdominal cavity causes pan-peritonitis, which is both rare and difficult to diagnose.

Case presentation: An 80-year-old man presented to our hospital with acute left upper abdominal pain. Twenty days prior to presentation, he had been admitted for 12 days with coronavirus disease 2019 (COVID-19). The patient had mild cholecystitis and received conservative therapy for COVID-19. Upon readmission, his abdomen was flat and soft except for local peritonitis in the left upper abdomen. An emergency laparoscopy revealed a perforation in the ventral wall of the gallbladder neck discharging pus under the lateral lobe of the liver without a gastrointestinal perforation. Therefore, a laparoscopic cholecystectomy and intra-abdominal lavage were performed. Based on the clinical and pathological findings, the GBP was suspected to be a rupture of the abscess in the Rokitansky-Aschoff sinus observed on magnetic resonance imaging during the first admission.

Discussion: In this case, acute cholecystitis was suppressed by conservative therapy, leaving adhesions of the surrounding tissue and viscus to the gallbladder fundus and body as well as an abscess in the wall of the neck. This was the cause of the GBP and resulted in local peritonitis within the left upper abdomen.

Conclusion: Type 1 GBP develops suddenly and cannot be predicted. In cases of acute cholecystitis once suppressed by conservative therapy and accompanied by cystic formation in the gallbladder wall, early cholecystectomy is recommended considering the risk of GBP.

Keywords: Acute cholecystitis; Covid-19; Exploratory laparoscopy; Laparoscopic cholecystectomy; Rokitansky-Aschoff sinus.

Fig. 1

Computed tomography scan taken during the initial admission showing a small high-density spot in the cystic duct as well as gallbladder distension and wall thickening.

Fig. 2

Magnetic resonance imaging scan taken 6 days after the initial admission showing a mass lesion in the wall of the gallbladder neck, isointensity on a T2-weighted image (A) and high intensity on a diffusion-weighted image (B).

Fig. 3

Computed tomography scan taken during the second admission showing gallbladder distention and wall thickening without free air or fluid collection in the abdominal cavity.

Fig. 4

Laparoscopic view showing a perforation of the gallbladder neck with pus discharge.

Fig. 5

(a) Macroscopic view of the resected specimen showing a gallbladder perforation without necrotic changes. (b) Microscopic findings of the gallbladder around the perforation showing disruption of the gallbladder wall and the infiltration of inflammatory cells. (c) Microscopic findings close to the perforation site showing adenomyomatosis and a dilated Rokitansky-Aschoff sinus.