Teaching Case

CASE REPORT – A 42-year old intoxicated male patient suffered from a blunt abdominal trauma 4 days before the admission. The physical examination was normal and no specific laboratory values were found.

A 42-year old medium built drunk male patient was injured and his abdomen was also kicked. On the fourth day after the trauma he presented himself in good general status in the hospital. His abdomen was soft and there were no defence or pathological resistance palpable. The patient described a marked pressure sensitivity under the right costal arch. The skin had a good turgor. The laboratory examinations revealed elevated white blood cell number, hyperbilirubinemia and elevated total protein level. Hemoglobin, hematocrit, blood sugar and amylase levels were in the normal range. The ultrasound examination showed an average size gallbladder with hyperechoic thickened wall and the content of the gallbladder was mostly hyperechoic and markedly inhomogeneous (Figure 1, 2). Adjacent to the gallbladder an irregular multiseptated fluid collection was present (Figure 3). The parenchymal abdominal organs didn’t reveal any traumatic or other abnormalities. CT outlined the pericholecystic fluid collection, which extended to the transverse colon. The lumen of the gallbladder appeared normally, but approximately 2.5 centimeters of the gallbladder wall on the medial side near the gallbladder neck were blurred. The density in the gallbladder lumen measured 60-70 HU, equivalent with blood. The pericholecystic fluid showed water-like density (Figure 4-6). The liver density was homogeneous on both pre-and postcontrast scans. The final diagnosis was confirmed at surgery.

Bunt abdominal trauma seldom causes an isolated gallbladder injury due to the protected anatomical location of the organ within the abdominal cavity. Most authors consider an increased pressure in the gallbladder or in the bile ducts during trauma as causative mechanism [1]. Predisposing factors are cholecystolithiasis, inflammation, tumour, a distended or ptotic gallbladder, and the alcoholic status[1,2,3]. In alcohol intoxicated persons the relaxed abdominal musculature is unable to show reflex protection [1] and alcohol also increases the Oddi’s sphincter tone resulting in biliary duct pressure elevation [4,5]. A multiphase clinical course is characteristic. After trauma an intense spastic pain appears first under the right costal arch and radiates under the right scapula [6]. The general status is usually good [2,7]. These initial symptoms are followed by a relatively symptom-free interval, which can take some hours, eventually some weeks. Symptoms of biliary peritonitis or hemorrhage dominate the third phase. The laboratory findings are not helpful if the bile leakage or the hemorrhage are small or encapsulated. The main abnormalities are leukocytosis, hyperbilirubinemia and later bilirubinemia. In massive hemorrhage decreased hemoglobin and hematocrit levels can be demonstrated [7-9]. An US examination should be the first imaging procedure. It demonstrates an irregular thickened wall and a hyperechoic gallbladder lumen, which is usually small and collapsed. Pericholecystic and subhepatic fluid can be seen. There is also focal loss of the gallbladder wall reflectivity [10,11,12]. On CT the collapsed gallbladder and the defect of the irregularly thickened wall can be seen as well. The high density of the gallbladder fluid indicates hemorrhage. The pericholecystic fluid collection or other associated lesions are also well demonstrated [10,11,13,14]. If the diagnosis is still not possible, MRCP may be helpful. On strongly T2-weighted scans essentially only stationary fluid (gallbladder, biliary ducts, pancreatic duct) will be shown [8,15]. Hepatobiliary scintigraphy can demonstrate free bile leakage [4,6,8,10]. This examination is performed with HIDA Tc99m, which is administrated intravenously and rapidly excreted in high concentration via the biliary ducts by the polygonal liver cells. The anatomically fixed location of the duodenum allows to determine the starting point of the bowel activity. If the intraabdominal radioactivity appears earlier than the bowel activity it can be diagnosed as extraluminally [16]. Peritoneal lavage is the most invasive method. Neither this examination nor the HIDA can determine the exact location of the lesion, because bile fluid can leak into the abdominal cavity from lesions of liver, gallbladder, bile duct, and proximal small intestine [3,7]. If funtional MRI following administration of a biliary contrast agent is available, there is no need for hepatobiliary scintigraphy, because the former is an expedient method for the diagnosis of bile duct or gallbladder leakage.