A major concern people have when they start to experience the pain of a gallbladder attack is whether or not the gallbladder is about to burst or if it already has. But a gallbladder attack is often accompanied by excruciating pain that has nothing to do with rupture. When the normal flow of bile gets disrupted, regardless of the mechanism, pain ensues. And when the gallbladder is blocked and distends, it may place pressure on the nerves causing the pain to refer to the back.
Signs and Symptoms of Impending Gallbladder Rupture
However, while the statistics are very low, the possibility of rupture is real, and being on the lookout for signs and symptoms of impending gallbladder rupture can allay some fears. Ruptures occurring from injuries are unavoidable, but you can watch for signs of cholecystitis (inflammation of the gallbladder). If the pain of a gallbladder attack lasts for 6 or more hours, and if there are chills or fever, seek medical attention where they can order imaging to get a better look at what’s going on.
The majority of reported cases with gallbladder rupture or perforation are due to acute cholecystitis. Statistics show that between 1-4% of patients with acute gallbladder inflammation may experience a rupture of the gallbladder. The risk is much higher for those with acalculous cholecystitis, also known as gallbladder inflammation without the presence of gallstones. In all these cases, the gallbladder body or fundus is the most common site of perforation since it is the part with the least blood supply.
Classifications of Gallbladder Perforations
Type 1- Free perforation
This type is also called acute perforation of the gallbladder. It is characterized by the free spillage of the bile and other gallbladder contents. It is usually accompanied by the inflammation of the membrane forming the abdominal cavity. Type 1 perforations are usually seen in patients with AHD, diabetes, malignancy, cirrhosis, and immunosuppressive diseases.
Type 2 – Perforation with abscess
This type of perforation is the most common among the four types encountered during surgery. It is also referred to as sub-acute perforation. It is characterized by the leakage of pericholecystic fluid at the site of gallbladder perforation, localized peritonitis (inflammation of tissue in the inner wall of the abdomen), and the painful collection of pus.
Type 3 – Chronic perforation with biliary fistula formation
Type 3 is also called chronic perforation of the gallbladder. Aside from the presence of the above-mentioned characteristics under type 1 and type 2 perforations, type 3 is identified by the occurrence of a cholecystoduodenal fistula. It is a rare complication that may happen to those with long-term cholecystitis and gallstones wherein the gallbladder sticks to the duodenum and a stone ulcerates through the wall.
Causes of Gallbladder Rupture or Perforation of the Gallbladder
Gallbladder perforation is also classified based on possible causes: spontaneous, traumatic, and iatrogenic.
This can be further broken down into two groups:
- Idiopathic causes are related to diseases or conditions that arise spontaneously without any apparent or proven cause. The diagnoses of such gallbladder rupture cases are often delayed or missed. These, fortunately, are rare.
- The second sub-category under spontaneous causes may include conditions such as gallstones, cholecystitis, infection, congenital obstruction, and more.
2. Traumatic causes
Due to injuries or accidents.
As the name implies, this type may be induced inadvertently by medical procedures, prescriptions, or therapy. The gallbladder may be perforated or burst completely due to mistakes in surgery, wrongly-administered drugs, or adverse effects of therapy. Some iatrogenic causes that have been cited in studies include complications during cholecystectomy, kidney biopsy, and liver biopsy.
Connection between Gallbladder Inflammation and Perforation
Acute cholecystitis is still the most common cause for gallbladder perforation or rupture. The mechanism could be due to the following:
1. Bile Stasis
Abnormal and significant change in bile content and concentration may be due to the following:
- nutrition and diet
2. Vascular Impairment
Decreased blood flow to the gallbladder may be brought about by any condition that affects gallbladder motility, impairment due to the distention of the gallbladder, or an underlying systemic illness like shock, sepsis, and atherosclerosis, among others.
3. Necrosis (cell death) and perforation of the gallbladder wall
Conditions Leading to Gallbladder Rupture and Perforation of the Gallbladder
Aside from acute cholecystitis, other conditions may lead to gallbladder rupture and perforation:
Gas in gallstones, more commonly known as the “Mercedes-Benz sign”, is actually not a gallbladder disease. Rather, it is a characteristic of gallstones sometimes discovered on an abdominal radiograph or CT scan. It is called such because it is a gallstone fissure which appears in a star-shaped pattern mimicking the famous logo. Fissures occur in about 50% of gallstones but having nitrogen gas in these fissures is not common. The presence of this Mercedes-Benz sign is an indication of a rare condition called emphysematous cholecystitis or clostridial cholecystitis, an acute gallbladder infection.
Causes and Impact of Gas in Gallstones
The exact reason for the existence of this gas is not certain. However, some hypothesize that it is due to the presence of gas-forming organisms in the biliary tract. Others believe that it is due to the rapid deposition of crystals on the gallstone surface causing inward diffusion of gas from the surrounding fluid.
Emphysematous cholecystitis is considered a surgical emergency. If not treated, it may lead to septic shock, cardiovascular collapse, or death. Emphysematous cholecystitis also significantly increases the possibility of gangrene and perforation of the gallbladder.
Another rare but serious condition due to chronic gallbladder inflammation is necrosis of the organ or gangrenous cholecystitis. Gangrene is a specific type of necrosis in which the blood supply causes the death of cells; necrosis itself is cell death by any cause, not necessarily lack of blood supply.
Gangrenous cholecystitis is a result of long-term enlargement, swelling, or distention of the gallbladder wall causing the inadequate blood supply to the gallbladder resulting in tissue death or necrosis.
Who are at risk of gangrenous cholecystis?
This condition is more likely to occur in older patients and is more prevalent among men. Those with existing diabetes mellitus, cardiovascular disease, and elevated white blood cell count are more at risk of suffering from gangrenous cholecystitis. Gangrenous cholecystitis develops in up to 20% of the cases with acute cholecystitis. There is also a higher risk of gallbladder perforation in up to 10% of patients with associated peritonitis, fistula and intra-peritoneal abscess formation.
Symptoms and Management of Gangrenous Cholecystitis
Aside from usual symptoms accompanying gallbladder inflammation, some of the indicators of gangrenous cholecystitis include high levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP), and total bilirubin as shown in laboratory tests. Some patients with gangrenous cholecystitis also exhibit gas in gallstones that is a characteristic of emphysematous cholecystitis.
The finding of gangrenous cholecystitis does not change the surgical management of cholecystitis. However, knowing that a patient has increased risk for gangrenous cholecystitis may prompt earlier surgical intervention.
Microorganisms have been directly and indirectly implicated in a number of studies investigating gallbladder infection, rupture, and perforation. Some specific organisms that were isolated from the research subjects are as follows:
- Escherichia coli
- Anaerobic Streptococci
- Species from genera Staphylococcus
One explanation for the identification of bacterial infection as cause for gallbladder infection and for gallbladder perforation is the colonization of the GI tract and penetration of the intestinal barrier. Because of this, bacteria can reach the gut-associated lymphoid tissue, infect phagocytic cells that enter the bloodstream, and spread systemically to multiple organs, most especially the liver and spleen. An infection within the biliary system can elicit a strong inflammatory response and cause tissue injury. This may eventually lead to gallbladder perforation or rupture.
Aside from bacterial infection, the biliary tract is also susceptible to parasitic invasion. Liver flukes causing chlonorchiasis, roundworms that cause ascariasis, and tapeworms like Taenia saginata that cause echinococcosis have been specifically studied in separate instances.
They have all been proven to be possible causes of biliary obstruction, gangrenous cholecystitis and eventually, gallbladder perforation or rupture.
Blunt injuries to the gallbladder are rare because its strategic anatomic location provides a natural “shield” against traumatic injuries. However, there are still remote instances when the organ may be perforated or ruptured. This happens to about 2-3% of all blunt abdominal trauma. Some incidences that may account for this possibility include:
- Car accidents (seat belt compression)
- Blunt force trauma to the abdomen
- Alcohol ingestion in the fasting state
Treatment for Gallbladder Perforation or Rupture
Whether the gallbladder has been perforated or it has completely ruptured, it is imperative to have an emergency surgical treatment.
A procedure for draining the fluid from the gallbladder through a tube or catheter called percutaneous cholecystostomy is sometimes performed if surgery is not an option. Occasionally, this method is also used for stone dissolution and stone extraction as an alternative to gallbladder removal.
Whatever the chosen mode of treatment may be, early diagnosis and standard testing is critical for timely medical response.
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