Gallbladder injury resulting from blunt abdominal trauma is a rare entity and generally associated with other intra-abdominal injuries. Incidence of isolated gallbladder injury has not been reported yet. The most common mechanism of injury reported is road traffic accident. Diagnosis is usually made on imaging as clinical presentation may vary from no symptoms to peritonitis due to extravasation of bile in the abdominal cavity. Cholecystectomy is the treatment of choice and minimally invasive approach can be considered in haemodynamically stable patients.
Keywords: Gallbladder injury, Blunt Trauma, Cholecystectomy.
Gallbladder injury resulting from blunt abdominal trauma is a rare entity and is usually associated with other visceral injuries. The low incidence is attributed to the protection provided by surrounding liver and rib cage. The reported incidence is 2% in patients undergoing laparotomy for blunt trauma.1 Isolated gallbladder injury is even rarer and the incidence has not been reported yet. Soderstorm et al2 reported 5 out of 30 cases of isolated gallbladder injuries. This was also described by Wiener et al3 reporting only half of the cases of gallbladder were in isolation.
Mechanism of Injury
Most blunt injuries results from motor vehicle accidents, falls or direct blow to the abdomen. Predisposing factors include thin wall and distended gallbladder and alcohol ingestion which increases the sphincter of Oddi tone thus increasing biliary pressure.4 Gallbladder injuries include lacerations, avulsions and contusions resulting from compressive and shearing forces. Laceration, also known as rupture is the most commonly reported injury. Avulsion is the second most common injury and has three subtypes: partial avulsion in which the gallbladder is partially torn from liver bed; complete avulsion in which the gallbladder is completely detached from liver bed but cystic duct and artery are intact and total avulsion in which the gallbladder is completely torn from its attachments and lies free in the abdomen. Contusion or intramural haematoma is often diagnosed at the time of laparotomy and is underreported, that can lead to delayed perforation due to wall necrosis.5 Losonaff and Kjossev described a detail classification of gallbladder injuries (Table-1).6
Clinical presentation of isolated gallbladder injury as a result of blunt abdominal trauma varies from subtle right upper quadrant pain to peritonitis in case of extravasation of bile from a perforated gallbladder. In case of subtle symptoms and low index of suspicion, patients might get discharged from hospital on symptomatic management.7 Consequently, such patients may present late with pain, fever, nausea, vomiting or jaundice secondary to intraabdominal collection of bile and /or with superadded infection or frank peritonitis.2 The clinical presentation is almost attributable to associated intraperitoneal injuries including solid, hollow viscous or vascular injuries on initial presentation.
Early diagnosis of gallbladder injury resulting from blunt abdominal trauma is crucial but is difficult to determine. No single radiographic evaluation has proven to have adequate sensitivity or specificity for diagnosing gallbladder injury from blunt abdominal trauma.8 Diagnostic modalities for identification of gallbladder trauma include ultrasonography, computerized tomography and HIDA scan. Ultrasound findings include thickened hypoechoic oedematous gallbladder wall, an echogenic pericholecystic fluid collection, heterogeneous hyperechoic blood within the gallbladder lumen, disruption of the gallbladder wall and collapse despite prolonged fasting. However, ultrasound is more useful for the evaluation of atraumatic gallbladder pathology.9 The most effective imaging modality in identifying gallbladder injury is contrast enhanced CT scan. Presence of hyperdense blood within gallbladder lumen is suggestive of gallbladder trauma.9 Other CT findings include pericholecystic fluid, thickened and indistinct gallbladder walls, a mass effect on the adjacent organs including liver, duodenum and right kidney due to gallbladder distention, displacement of gallbladder from its fossa due to complete avulsion and active arterial contrast extravasation into gallbladder lumen.10 Delayed phase images are vital in differentiating true gallbladder haemorrhage from other non-traumatic pathologies because of an increase in the amount of dense fluid or extravasation as the haemorrhage progresses.4 Hepatobiliary scintigraphy can be used in equivocal cases which can detect the extravasation of radioisotope due to bile leakage from gallbladder.11 Magnetic resonance imaging can detect areas of mural discontinuity due to superior soft tissue resolution, however, its use is limited in trauma settings due to long examination times.12
Gallbladder injury can be potentially life-threatening, and early management is imperative. Cholecystectomy is the treatment of choice for traumatic gallbladder injuries. However, treatment approach depends on the type of injury, extent of associated injuries and general condition of the patient. In patients undergoing laparotomy for associated injuries, cholecystectomy is the treatment of choice. However, minimally invasive approach in the form of laparoscopic cholecystectomy is a safe option in stable patients without major associated injuries. Patients with mild injuries like isolated partial avulsion or contusion of gallbladder with polytrauma without associated abdominal injury can be observed with conservative management, although late necrosis and perforation have been reported.5
Literature search was done using PubMed and Google Scholar to find studies mentioning isolated gallbladder rupture resulting from blunt abdominal trauma from January 1980 till April 2019. Search term used were 'isolated gallbladder injury' and 'blunt abdominal trauma'. Total of 28 full text studies were selected to review the presentation, mechanism of injury and management of patients with isolated gallbladder injuries (Table-2).
Available literature suggests that, although a rare entity, isolated gallbladder injury has been reported in literature; however, the true incidence has not been calculated as yet. The most common mechanism in the reported cases was road traffic accident. Except for the one case of delayed presentation,28 all patients presented early to hospital after injury and the most common symptomatology was right upper quadrant pain. Radiological imaging was used to diagnose the injury in all cases however; the exact type of injury according to Losanoff and Kjossev6 was not mentioned in every case. Cholecystectomy was the standard of care in nearly all cases except for one case who was an elderly high risk patient with multiple comorbid conditions and was managed with intraperitoneal drain placement and ERCP. Minimally invasive approach in the form of laparoscopic cholecystectomy was performed in haemodynamically stable patients.
Conflict of Interest: None.
Source of Funding: None.
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