What is the management of a ruptured gallbladder diagnosed after 1 week?

Management of Ruptured Gallbladder After 1 Week

The management of a ruptured gallbladder diagnosed after 1 week requires percutaneous drainage of fluid collections, targeted broad-spectrum antibiotics, nutritional support, and delayed definitive surgical intervention with Roux-en-Y hepaticojejunostomy after stabilization of the patient's condition. 1

Initial Assessment and Stabilization

• Diagnostic Imaging:

  • Abdominal triphasic CT as first-line investigation to detect intra-abdominal fluid collections and ductal dilation 1
  • Complement with CE-MRCP for exact visualization, localization, and classification of bile duct injury 1

• Laboratory Evaluation:

  • Assess liver function tests (direct/indirect bilirubin, AST, ALT, ALP, GGT, albumin)
  • In critically ill patients, monitor CRP, PCT, and lactate levels to evaluate severity of inflammation/sepsis 1

Immediate Management (First 24-48 Hours)

1. Source Control:

   • Urgent percutaneous drainage of biliary collections/bilomas 1
   • If diffuse biliary peritonitis is present, urgent abdominal cavity lavage and drainage are required 1

2. Antibiotic Therapy:

   • Start antibiotics immediately (within 1 hour) for patients with biliary fistula, biloma, or bile peritonitis 1
   • Recommended regimen:
     • Piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem
     • Add amikacin in cases of shock
     • Consider fluconazole in fragile patients and cases of delayed diagnosis 1

3. Supportive Care:

   • Provide nutritional support 1
   • Maintain fluid and electrolyte balance
   • Monitor for signs of sepsis or organ dysfunction

Intermediate Management (1-3 Weeks)

• Continue Percutaneous Drainage:

  • Ensure adequate drainage of all collections
  • Monitor drain output and characteristics

• Endoscopic Intervention:

  • Consider ERCP with sphincterotomy with/without stent placement to reduce pressure gradient in the biliary tree 1
  • PTBD (Percutaneous Transhepatic Biliary Drainage) may be useful for septic patients with complete obstruction of common bile duct 1

• Antibiotic Duration:

  • 4 days in immunocompetent, non-critically ill patients if source control is adequate 1
  • Up to 7 days based on clinical condition and inflammation markers in immunocompromised or critically ill patients 1
  • Patients with ongoing signs of infection beyond 7 days warrant further diagnostic investigation 1

Definitive Management (After 3+ Weeks)

• Surgical Repair:

  • After a minimum of 3 weeks, if patient's general condition allows and acute/subacute situation is resolved (e.g., closure of biliary fistula), perform Roux-en-Y hepaticojejunostomy 1
  • Referral to a center with expertise in HPB procedures is strongly recommended if local expertise is unavailable 1

• Surgical Principles:

  • Ensure tension-free bilioenteric anastomosis with good mucosal apposition 2
  • Build anastomosis upon healthy, non-ischemic, non-inflamed bile duct tissue 2
  • Create a wide anastomosis (minimum 15mm) to prevent stricture formation 2

Special Considerations

• Vascular Injuries:

  • Assess for concomitant vascular injuries (hepatic artery, portal vein)
  • If vasculobiliary injuries are present, surgical management should be delayed to allow for accurate imaging workup and strategic planning 1

• Complex Cases:

  • Non-referral to specialized centers can lead to poor outcomes 2
  • Complex cases should be managed at tertiary centers with HPB expertise 2

Pitfalls to Avoid

1. Premature Surgery:

   • Attempting immediate repair in the setting of inflammation and tissue edema can lead to poor outcomes
   • Allow 3+ weeks for inflammation to subside before definitive repair 1

2. Inadequate Source Control:

   • Failure to adequately drain all biliary collections can lead to persistent sepsis
   • Ensure complete drainage of all collections before definitive repair

3. Misclassification of Injury:

   • Underestimating the extent of biliary injury can lead to inappropriate management
   • Comprehensive imaging with MRCP is essential for accurate classification 2

4. Antibiotic Misuse:

   • Prolonging antibiotics beyond 7 days without clear indication
   • Patients with ongoing signs of infection beyond 7 days need further investigation rather than continued antibiotics 1