What is an imploding gallbladder (perforated gallbladder)?

What is an Imploding (Perforated) Gallbladder?

An "imploding" or perforated gallbladder is a life-threatening complication of acute cholecystitis in which the gallbladder wall ruptures due to ischemic necrosis from fulminant inflammation and infection, occurring in 2-11% of acute cholecystitis cases with a mortality rate of 12-16%. 1, 2

Pathophysiology

• Gallbladder perforation develops when acute cholecystitis progresses to ischemic necrosis of the gallbladder wall, leading to rupture and spillage of bile and infected material into the peritoneal cavity or adjacent tissues. 1

• The fundus is the most common perforation site (69% of cases), followed by the body (17%), Hartmann's pouch (11%), and cystic duct (3%), because the fundus has the poorest blood supply and is most vulnerable to ischemic injury. 3

• Perforation typically occurs in patients with severe systemic disease (diabetes mellitus, atherosclerotic heart disease) who often lack a prior history of acute cholecystitis, distinguishing it from chronic presentations. 1, 2

Niemeier Classification System

Gallbladder perforation is classified into three distinct types, each with different clinical presentations, risk profiles, and management approaches: 1, 2, 4

Type I - Acute Free Perforation

• Presents with generalized peritonitis from free perforation into the peritoneal cavity, typically occurring at the fundus. 1, 2
• Carries the highest immediate mortality risk due to widespread peritoneal contamination and requires emergency surgical intervention. 2
• Occurs in approximately 40.6% of gallbladder perforations (range 16.7-70.0%). 4

Type II - Subacute Perforation with Pericholecystic Abscess

• Presents with localized peritonitis when perforation in the body or neck becomes walled off by omentum, creating a pericholecystic abscess. 1, 2
• Most common perforation type, accounting for 46.2% of cases (range 7.4-83.3%). 4
• Brief stabilization is permitted before surgery, which involves cholecystectomy and abscess drainage. 5

Type III - Chronic Perforation with Cholecystoenteric Fistula

• Presents as a chronic fistula between the gallbladder and adjacent bowel, typically in elderly patients with recurrent cholecystitis. 1, 2
• Least common type at 10.1% of perforations (range 0-48.1%) and generally has lower mortality due to indolent presentation. 2, 4
• Requires elective repair with laparoscopic cholecystectomy and fistula repair; failure to control both gallbladder and enteric components results in persistent sepsis. 5, 2

Diagnostic Challenges

Preoperative diagnosis is rare, with only 27.8% of perforations diagnosed before surgery, because clinical presentation mimics uncomplicated acute cholecystitis with nonspecific symptoms. 2, 3, 6

Ultrasound Findings

• Ultrasound shows findings similar to acute cholecystitis (pericholecystic fluid, distended gallbladder, wall thickening, gallstones, positive Murphy's sign). 1
• The sonographic "hole sign" (visualization of a defect in the gallbladder wall) can suggest perforation but is not consistently present. 1, 2

CT Scan Findings (Superior Diagnostic Modality)

• CT scan is more reliable than ultrasound for demonstrating the actual defect in the gallbladder wall, pericholecystic collections, and free intraperitoneal fluid. 1, 2, 7
• Direct CT signs include calculi outside the gallbladder and visualization of the ruptured wall segment; indirect signs include localized abscesses (occasionally multiple or distant), gallstones, and gallbladder wall thickening. 7

Critical Management Principles

Early diagnosis and immediate surgical intervention substantially reduce morbidity, mortality, ICU admission rates, and length of hospitalization. 1, 5, 2

Immediate Surgical Intervention

• Immediate laparoscopic or open cholecystectomy with extensive peritoneal lavage is the standard of care for any patient who can tolerate surgery (Recommendation 1C). 1, 5
• Do not postpone surgery based on concerns about technical difficulty or potential bile duct injury—the documented mortality of delayed intervention (12-16%) far outweighs these concerns. 5, 2
• Delayed diagnosis beyond 6 hours significantly increases mortality, prolongs hospital stay, and necessitates more complex surgical intervention. 2

Role of Percutaneous Cholecystostomy

• Percutaneous cholecystostomy is recommended ONLY for critically ill or severely comorbid patients who are unfit for surgery (Recommendation 1B). 1, 5
• In surgical candidates, routine use of percutaneous drainage followed by interval cholecystectomy leads to worse outcomes and should be avoided. 5

Antibiotic Management

• Broad-spectrum antibiotics covering Gram-negative and anaerobic organisms must be initiated immediately, including piperacillin/tazobactam, imipenem/cilastatin, meropenem, or ertapenem. 5
• Among patients with uncomplicated cholecystitis, if source control is complete, no postoperative antimicrobial therapy is necessary. 1

Common Pitfalls to Avoid

• Do not wait for definitive imaging confirmation if clinical suspicion is high—proceed with urgent surgical consultation even with equivocal imaging. 2
• Avoid conservative management in Type I perforation, which requires immediate surgical intervention with cholecystectomy and extensive peritoneal lavage. 2
• Do not use ERCP as primary therapy—while ERCP is the treatment of choice for acute cholangitis and post-operative bile leaks, it does not address the source of contamination in gallbladder perforation with peritonitis. 5
• In Type III cholecystoenteric fistulas, failure to control both the gallbladder and enteric components results in persistent sepsis and abscess formation. 2