Management of Ruptured Gallbladder After 1 Week
For a ruptured gallbladder diagnosed after 1 week, urgent percutaneous drainage of biliary collections/bilomas is necessary, along with immediate antibiotic therapy and appropriate surgical intervention after the acute situation resolves. 1
Diagnostic Approach
When managing a ruptured gallbladder diagnosed after 1 week, proper imaging and laboratory evaluation are essential:
- First-line imaging: Abdominal triphasic CT to detect intra-abdominal fluid collections and ductal dilation 1
- Complementary imaging: CE-MRCP for exact visualization, localization, and classification of bile duct injury 1
- Laboratory tests:
- Liver function tests (direct/indirect bilirubin, AST, ALT, ALP, GGT, albumin)
- Inflammatory markers (CRP, PCT, lactate) to evaluate severity of inflammation/sepsis 1
Immediate Management
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
Antibiotic Therapy
- Start antibiotics immediately (within 1 hour) for patients with biliary fistula, biloma, or bile peritonitis 1
- Recommended regimens:
- First-line: Piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem
- Add amikacin in cases of shock
- Consider fluconazole in fragile patients and cases of delayed diagnosis (particularly relevant for diagnosis after 1 week) 1
- Duration:
- 4 days in immunocompetent, non-critically ill patients if source control is adequate
- Up to 7 days in immunocompromised or critically ill patients based on clinical condition and inflammation markers 1
Supportive Care
- Provide nutritional support
- Maintain fluid and electrolyte balance
- Monitor for signs of sepsis or organ dysfunction 1
Interventional Procedures
- 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 the common bile duct 1
Definitive Surgical Management
- After a minimum of 3 weeks (once the acute/subacute situation is resolved):
- Perform Roux-en-Y hepaticojejunostomy if the patient's general condition allows 1
- Surgical principles:
- Ensure tension-free bilioenteric anastomosis with good mucosal apposition
- Build anastomosis upon healthy, non-ischemic, non-inflamed bile duct tissue
- Create a wide anastomosis (minimum 15mm) to prevent stricture formation 1
Special Considerations
- Vascular injuries: Assess for concomitant vascular injuries (hepatic artery, portal vein)
- Vasculobiliary injuries: Delay surgical management to allow for accurate imaging workup and strategic planning 1
- Complex cases: Refer to tertiary centers with HPB expertise, as non-referral to specialized centers can lead to poor outcomes 1
Important Caveats
- Delayed diagnosis (after 1 week) increases the risk of complications including sepsis and peritonitis
- The diagnosis can be challenging and may be confused with other conditions such as liver tumors or hematomas 2
- Patients with diabetes mellitus, those older than 60, or with an ASA classification of 3 or more have higher risk of complications and may require more aggressive management 3