Radiological case of the month: Mitchell J. Mendrek, MD; Juan R. Rodriguez, MD; Mardjohan Hardjasudarma, MD.
Mendrek, Mitchell J.
Rodriguez, Juan R.
|Publication:||Name: Applied Radiology Publisher: Anderson Publishing Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2006 Anderson Publishing Ltd. ISSN: 0160-9963|
|Issue:||Date: Sept, 2006 Source Volume: 35 Source Issue: 9|
A 26-year-old man was transferred to our institution after sustaining a motor vehicle accident. Upon arrival, the patient was evaluated by trauma surgery and emergency radiology. The patient was alert, oriented, and hemodynamically stable. The drug screen was positive for opiates and alcohol. He reported pain in the right hip and abdomen. Seat-belt bruises were noted crossing from the left shoulder to the right flank. A posterior hip dislocation was evident on physical examination and plain radiographs. A fast scan performed with a portable ultrasound unit by a radiologist was positive for fluid in the hepatorenal fossa. A computed tomography (CT) of his abdomen and pelvis was performed with the administration of oral and intravenous contrast media for further evaluation.
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Traumatic rupture of the gallbladder
Contrast-enhanced CT shows the presence of pericholecystic fluid (Figure 1) as well as fluid in hepatorenal fossa (Figure 2). The gallbladder presents an ill-defined contour and appears partially contracted; an increase in attenuation in its lumen is compatible with blood (Figure 3). The rest of the examination was unremarkable, with the exception of the previous known posterior right hip dislocation.
Gallbladder injuries following trauma are rare. Damage to the extrahepatic biliary system and the gallbladder occurs in 2% of cases of blunt abdominal trauma. (1,2) These data were obtained from surgical findings at laparotomy prior to the routine use of ultrasound and CT. It is possible that these results underestimate the true incidence of this traumatic lesion. Isolated injuries are even more uncommon. In a series of 31 patients with gallbladder injuries, only 1 patient had no evidence of other intraperitoneal lesions. (1) In the other 30 patients, there were 75 associated intra-abdominal injuries.
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Gallbladder trauma is classified as contusion, laceration or perforation, or avulsion. (3) The least frequent of these injuries is contusion. However, gallbladder contusion probably occurs more commonly than has been published. The importance of contusion should not be ignored. The contused area may undergo necrosis and perforation. (4)
Penn (2) added traumatic cholecystitis as a type of traumatic gallbladder injury. The presence of blood in the biliary system (hemobilia) could cause the obstruction of the cystic duct, resulting in cholecystitis and possibly gangrene and perforation. (2) The formation of fistulae and its relation with trauma has also been reported. (5,6)
Prior to the introduction of CT, preoperative diagnosis of gallbladder injuries due to trauma was rarely made. Most of the cases reported were incidental findings at laparotomy or after the development of complications including bile peritonitis and sepsis. (1) Case reports that document the sonographic and CT appearance of traumatic gallbladder injuries are available in the literature. (7-10)
Free fluid in the peritoneal cavity and fluid in pericholecystic distribution are nonspecific signs. Periportal edema, hemorrhage, ascites, or extravasated bile could account for these findings. Loss of definition of the contour of the organ is highly suggestive of gallbladder injury. However, this appearance does not mean perforation or avulsion--it means only that injury to the wall has occurred. (11) High-attenuation material in the lumen of the gallbladder could represent hemorrhage; conditions that may simulate blood include vicarious excretion of contrast medium, milk-of-calcium bile, and cholelithiasis.
The mechanism of gallbladder injury in blunt trauma involves compression and shearing forces. Three factors that influence the risk of injury have been proposed: a chronically diseased gallbladder wall is less likely to sustain significant trauma than is a normal wall; gallbladder distention at the time of the accident may increase the risk of injury; and alcohol ingestion may also increase the risk secondary to its effect on the sphincter of Oddi. (12)
Gallbladder injuries are treated by cholecystectomy. Percutaneous drainage may be useful in unstable patients. In those cases in which a contusion is suspected, a follow-up examination is indicated. A hepatobiliary scan could be useful to detect bile extravasation.
Rupture of the gallbladder after blunt trauma is a rare event. Some of the signs of gallbladder injury seen in this case and others available in the literature are nonspecific. The loss of contour of the organ with associated high attenuation in its lumen should alert the radiologist of this possibility. The widespread availability of ultrasound and multidetector CT in the emergency department makes the preoperative diagnosis possible. The close collaboration with emergency personnel and trauma surgeons is also key for accurate and prompt diagnosis of traumatic injuries.
(1.) Soderstrom CA, Maekawa K, DuPriest RW Jr, Cowley RA. Gallbladder injuries resulting from blunt abdominal trauma: An experience and review. Ann Surg. 1981;193:60-66.
(2.) Penn I. Injuries to the gall-bladder. Br J Surg. 1962;49:636-641.
(3.) Smith SW, Hastings TN. Traumatic rupture of the gallbladder. Ann Surg.1954;139:517-520.
(4.) Hicks JA. Case of traumatic perforation of gallbladder in child of 3 years. Br J Surg. 1944;31:305.
(5.) Grimes OF, Steinbach HL. Traumatic cholecystocutaneous fistula. Arch Surg. 1955;71:68-70.
(6.) Griffith CDM, Saunders JH. Cholecystoduodenocolic fistula following abdominal trauma. Br J Surg. 1982;69:99-100.
(7.) Gottesman L, Marks RA, Khoury PT, et al. Diagnosis of isolated perforation of the gallbladder following blunt trauma using sonography and CT. J Trauma. 1984;24:280-281.
(8.) Jeffrey RB Jr, Federle MP, Laing FC, Wing VW. Computed tomography of blunt trauma to the gallbladder. J Comput Assist Tomogr. 1986;10:756-758.
(9.) Ball DS, Friedman AC, Radecki PD, Caroline DF. Avulsed gallbladder: CT appearance. J Comput Assist Tomogr. 1988;12:538-539.
(10.) Carrillo EH, Lottenberg L, Saridakis A. Blunt traumatic injury of the gallbladder. J Trauma. 2004;57:408-409.
(11.) Erb RE, Mirvis SE, Shanmuganathan K. Gallbladder injury secondary to bunt trauma: CT findings. J Comput Assist Tomogr. 1994;18:778-784.
(12.) Smith EH, Soderberg CH Jr. Traumatic rupture of the gallbladder. RI Med J. 1964;47:29-30.
Prepared by Mitchell J. Mendrek, MD, Juan R. Rodriguez, MD, and Mardjohan Hardjasudarma, MD, Department of Radiology, Louisiana State University Health Sciences Center-Shreveport, Shreveport, LA.
* MDCT GE LightSpeed 16 (GE Healthcare, Waukesha, WI)
* Omnipaque 350 (GE Healthcare, Princeton, NJ)
* MD Gastroview (Tyco Healthcare/Mallinckrodt, St. Louis, MO)
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