How is peritonitis from gallbladder (cholecystic) perforation managed?

Management of Peritonitis from Gallbladder Perforation

Early diagnosis of gallbladder perforation and immediate surgical intervention is essential for decreasing morbidity and mortality rates in peritonitis from gallbladder perforation. 1

Diagnosis

Clinical Presentation

• Symptoms: Abdominal pain, tenderness, distension, fever, nausea, vomiting
• Signs: Peritoneal signs, shock (in severe cases)
• Risk factors: Severe systemic diseases (diabetes, atherosclerotic heart disease), advanced age, delayed treatment 1, 2

Laboratory Assessment

• Complete blood count (elevated WBC)
• C-reactive protein (elevated)
• Liver function tests (may show cholestatic pattern)
• In critically ill patients: Procalcitonin, lactate levels 1

Imaging

• CT scan is more reliable than ultrasound for diagnosing perforation 1, 2
• Key findings: Defect in gallbladder wall, pericholecystic fluid collection, free intraperitoneal fluid
• Sonographic "hole sign" in gallbladder wall may be visible on ultrasound 1

Classification of Gallbladder Perforation

1. Type I (acute): Free perforation with generalized peritonitis
2. Type II (subacute): Pericholecystic abscess with localized peritonitis
3. Type III (chronic): Cholecysto-enteric fistula 1, 3

Management Algorithm

1. Initial Resuscitation

• Fluid resuscitation
• Correction of electrolyte imbalances
• Hemodynamic stabilization

2. Antimicrobial Therapy

• Start broad-spectrum antibiotics immediately when peritonitis is suspected 2
• Recommended regimens:
  • Piperacillin/tazobactam (13.5g daily divided in 4 doses) 4
  • Alternative options: Tigecycline, Ciprofloxacin plus Metronidazole, Carbapenems for severe cases 2
• Adjust based on bile culture findings
• Duration: 5-7 days for generalized peritonitis 1

3. Definitive Management

• Surgical intervention is the mainstay of treatment 1
  • Laparoscopic cholecystectomy is preferred when feasible 1, 2
  • Open cholecystectomy may be necessary in complicated cases or when anatomy cannot be clearly identified 1
  • Peritoneal lavage and drainage

4. Special Considerations

• For critically ill patients unfit for immediate surgery:
  • Percutaneous cholecystostomy as a temporizing measure 1, 5
  • Percutaneous drainage of intra-abdominal collections 5
• For severe complicated intra-abdominal sepsis:
  • Open abdomen therapy may be considered for optimal source control 2

Monitoring and Follow-up

• Serial clinical and laboratory monitoring
• Follow-up imaging to ensure resolution of collections
• Monitor for complications: sepsis, organ failure, recurrent biliary issues

Outcomes and Prognosis

• Mortality rates for gallbladder perforation: 12-16% 1, 2
• Factors associated with worse outcomes:
  • Delayed diagnosis and treatment
  • Advanced age
  • Comorbidities
  • Type I perforation (generalized peritonitis)

Common Pitfalls

1. Delayed diagnosis: Perforation is rarely diagnosed pre-operatively; maintain high index of suspicion 1
2. Delayed surgical intervention: Associated with increased morbidity, mortality, ICU admission, and prolonged hospitalization 1
3. Inadequate source control: Ensure complete drainage of collections and appropriate surgical management
4. Inadequate antimicrobial coverage: Ensure coverage of common biliary pathogens including Enterobacteriaceae and anaerobes 6

Gallbladder perforation with peritonitis represents a surgical emergency that requires prompt diagnosis and treatment. The combination of appropriate antimicrobial therapy and timely surgical intervention is crucial for improving outcomes in these patients.