What is the management for a gallbladder rupture?

Management of Gallbladder Rupture

For gallbladder rupture, immediate surgical intervention with cholecystectomy is the definitive treatment, with laparoscopic approach preferred in hemodynamically stable patients and open surgery reserved for unstable patients or when associated injuries are suspected. 1, 2, 3

Initial Assessment and Stabilization

Hemodynamic status determines the urgency and approach to surgical intervention. 1

• Initiate broad-spectrum antibiotics immediately (within 1 hour) covering Gram-negative and anaerobic organisms—use piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem. 4
• IV fluid resuscitation must be started immediately to achieve hemodynamic stabilization. 1
• NPO status is mandatory until surgical intervention. 1
• Obtain contrast-enhanced CT scan to assess extent of bile contamination, presence of associated injuries, and guide surgical planning. 1, 3

Classification and Clinical Context

Gallbladder rupture is classified into three types, which directly impact management strategy: 1

• Type I (free perforation): Generalized peritonitis requiring immediate surgery
• Type II (pericholecystic abscess): Localized peritonitis, may allow brief stabilization
• Type III (chronic fistula): Typically in elderly with recurrent cholecystitis, requires elective repair

Surgical Management Strategy

For Hemodynamically Stable Patients

Laparoscopic cholecystectomy is the preferred approach for isolated gallbladder rupture in stable patients. 1, 2, 3

• Complete abdominal exploration is essential to assess extent of peritoneal contamination, presence of gallstones, condition of surrounding structures, and any additional perforations. 1
• Thorough irrigation and drainage of the peritoneal cavity must be performed. 3
• Place abdominal drains in the right upper quadrant. 4, 1
• If a cholecysto-enteric fistula is present, perform primary repair or resection of the fistula tract with biopsies to exclude malignancy. 1

For Hemodynamically Unstable Patients or Multiple Injuries

Open laparotomy is mandatory when hemodynamic instability exists or when associated intra-abdominal injuries are suspected. 5

• Almost all gallbladder injuries from blunt trauma are associated with other significant intra-abdominal injuries, necessitating detailed exploration of the peritoneal cavity. 5
• In severe complicated intra-abdominal sepsis with organ failure and gross contamination, open abdomen can be considered. 4
• Damage control surgery principles apply: cholecystectomy, control of contamination, and abbreviated procedure with planned re-exploration. 4

Management of Specific Scenarios

Traumatic Gallbladder Rupture

For isolated traumatic gallbladder rupture diagnosed preoperatively, laparoscopic cholecystectomy is safe and effective. 2, 3

• If accumulated fluids contain bile, endoscopic cholangiography (ERCP) is useful not only to diagnose gallbladder injury but also to determine therapeutic strategy. 3
• A stiff, cirrhotic liver may exacerbate shear forces and represents an important risk factor requiring heightened suspicion. 5

Gallbladder Perforation with Fistula Formation

For Type III perforation with cholecysto-enteric fistula, laparoscopic cholecystectomy with fistula repair is the preferred approach in stable patients. 1

• Primary repair is recommended for small perforations (<2 cm) with minimal contamination. 1
• Segmental resection with primary anastomosis is required if extensive tissue damage or concern for viability exists. 1
• Diversion (temporary colostomy) should be considered with significant peritoneal contamination, hemodynamic instability, or multiple comorbidities. 1

High-Risk Surgical Candidates

Percutaneous cholecystostomy with drainage serves as a temporizing measure in patients with prohibitive surgical risk, followed by delayed definitive surgery when stabilized. 1

• This approach is appropriate for patients with severe comorbidities, advanced age, or ASA classification ≥3. 6
• Definitive cholecystectomy should be performed once the patient's condition improves. 1

Antibiotic Management

Broad-spectrum antibiotics must be initiated immediately and continued until clinical improvement. 4, 1

• For patients with previous biliary infection or preoperative stenting, use 4th-generation cephalosporins with adjustments according to antibiograms. 4
• In biliary fistula, biloma, or bile peritonitis, use piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem. 4
• Add amikacin in cases of shock and fluconazole in fragile patients or delayed diagnosis. 4

Important caveat: Routine antibiotics are NOT necessary for simple accidental gallbladder perforation during elective laparoscopic cholecystectomy in low-risk patients. 6 However, antibiotics should be started preoperatively in patients with diabetes mellitus, age >60 years, ASA ≥3, or expected operation time >70 minutes. 6

Postoperative Management

ICU admission is recommended for moderate to severe cases with significant peritonitis. 1

• Nasogastric tube decompression is necessary to prevent anastomotic stress if bowel repair was performed. 1
• Serial clinical evaluations are crucial to detect complications early, including abscess formation, bile leak, or anastomotic complications. 1
• Continue broad-spectrum antibiotics until clinical improvement is documented. 4, 1

Critical Pitfalls to Avoid

Delayed diagnosis is associated with significantly elevated mortality (12-16%), making urgent surgical consultation paramount even when imaging is equivocal. 1

• The signs and symptoms of ruptured gallbladder can be confusing, particularly in pregnancy or elderly patients. 7
• Delay in diagnosis for several days due to vague symptoms and insidious course is common but results in significant morbidity and mortality. 2
• Inadequate source control of both the gallbladder and any enteric fistula components leads to persistent sepsis and abscess formation. 1
• Failure to perform complete abdominal exploration may miss associated injuries, particularly in trauma cases. 5