Can a hematoma in the gallbladder fossa cause abdominal pain?

Can a Hematoma in the Gallbladder Fossa Cause Abdominal Pain?

Yes, a hematoma in the gallbladder fossa absolutely causes abdominal pain and should be recognized as a clinically significant finding requiring evaluation and management.

Clinical Presentation

A gallbladder fossa hematoma typically presents with:

• Right upper quadrant pain that can be sudden in onset, particularly in traumatic cases 1, 2, 3
• Subxiphoid pain extending to the right upper quadrant 3
• Positive Murphy's sign on physical examination 1
• Pain onset may occur immediately after trauma or be delayed by days to weeks 2, 4

The pain mechanism relates to:

• Distension of the gallbladder wall or fossa from blood accumulation 1, 3
• Peritoneal irritation if the hematoma extends beyond the gallbladder 3, 5
• Mass effect on surrounding structures 1

Diagnostic Approach

CT scan with IV contrast is the imaging modality of choice for evaluating suspected gallbladder fossa hematomas 6. This provides:

• Identification of high-density material in or around the gallbladder 1, 4
• Assessment of hematoma extent and associated injuries 2, 3
• Detection of active bleeding or complications 3, 5

Ultrasound can identify:

• Non-shadowing low-level echoes representing blood clots 4
• Gallbladder wall thickening and distension 1
• Useful for follow-up assessment 6

Clinical Context and Risk Factors

Gallbladder fossa hematomas occur in several settings:

Traumatic causes:

• Blunt abdominal trauma with or without liver injury 2, 4
• The gallbladder is classified as Grade I injury (contusion/hematoma) in the AAST organ injury scale 6
• May be associated with liver lacerations and hemoperitoneum 2

Non-traumatic causes:

• Hemorrhagic cholecystitis in anticoagulated patients 3
• Spontaneous bleeding in patients with coagulopathy or cirrhosis 4
• Can mimic gallbladder neoplasm on imaging 1

Management Strategy

For traumatic gallbladder hematomas (Grade I injuries):

• Hemodynamically stable patients without peritonitis should be managed conservatively with serial clinical monitoring 6
• Follow-up imaging is indicated if new symptoms develop including abdominal distention, tenderness, fever, or jaundice 6
• Cholecystectomy is indicated if the hematoma is associated with gallbladder laceration, perforation, or avulsion 6

For complicated presentations:

• Hemodynamic instability or signs of ongoing bleeding require urgent intervention 3
• Delayed perforation can occur days after initial injury, presenting with peritonitis 2
• Surgical exploration should be considered early in gallbladder injuries to prevent delayed complications 2

Critical Pitfalls to Avoid

• Do not dismiss persistent right upper quadrant pain after trauma, even if initial imaging appears benign—delayed complications including perforation can occur up to 7 days later 2
• Do not confuse gallbladder hematoma with neoplasm—both can present as mass lesions on imaging, but clinical history (trauma, anticoagulation) is key 1
• Do not assume stability means resolution—patients with gallbladder injury require serial hemoglobin monitoring and clinical reassessment for delayed bleeding or perforation 6, 2
• Recognize high-risk patients: those on anticoagulation, with cirrhosis, or who received thrombolytics are at increased risk for hemorrhagic complications 3, 4