Gastroenterology
Volume 138, Issue 4 , Page 1250, April 2010

Abdominal Distension in a 79-Year-Old Patient

  • Jung-Chun Lin, MD

      Affiliations

    • Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C.
    • ,
  • Heng-Cheng Chu, MD, PhD

      Affiliations

    • Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C.
    • ,
  • Daniel Hueng-Yuan Shen, MD, PhD

      Affiliations

    • Department of Nuclear Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, R.O.C.

published online 02 March 2010.

David A. Katzka and David L. Jaffe, Section Editors

Article Outline

 

Question: A 79-year-old man was referred to our hospital because of large-volume ascites found on abdominal ultrasound. He presented a 1-month history of progressive abdominal distension without pain or fever. Two months before presentation, the patient was in a motor vehicle accident and suffered blunt trauma to the right upper abdominal quadrant. Isolated contusion of the gallbladder was diagnosed owing to the presence of intraluminal hematomas in the gallbladder with no evidence of liver laceration based on abdominal computed tomography (CT) findings (Figure A). At that time, the patient was treated conservatively and discharged.

Physical examination revealed mild jaundice and shifting dullness without peritoneal signs. Laboratory data were notable for anemia (10.7 g/dL), hypoalbuminemia (2.8 g/dL), hyperbilirubinemia (2.5 mg/dL), and elevation of alkaline phosphatase (506 U/L). An abdominal CT scan showed massive ascites (Figure B). Diagnostic paracentesis produced a dark, greenish-brown peritoneal fluid (Figure C), with a bilirubin level of 16.8 mg/dL. Endoscopic retrograde cholangiopancreatography failed to determine the site of the bile leakage. 99mTc-DISIDA cholescintigraphy was performed (Figure D).

What is the diagnosis?

Look on page 1634 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

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Answer to the Clinical Challenges and Images in GI Question: Image 1 (page 1250): Traumatic Delayed Rupture of the Gallbladder 

The nuclear medicine scan (Figure E) demonstrated spread of the “leaked” tracer from the gallbladder to the peritoneal cavity within 1 hour. The diagnosis is traumatic delayed rupture of the gallbladder. Injury to the gallbladder from blunt abdominal trauma is uncommon, with an incidence of 2.1%, because of its protected anatomic location providing bony and visceral cushions.1, 2 The most common cause is motor vehicle crashes.1, 2 Injuries to the gallbladder can be classified as rupture (also termed laceration or perforation), avulsion, contusion, traumatic cholecystitis, traumatic biliary peritonitis without perforation, cholecystocutaneous fistula, and cholecystoduodenocolic fistula.1, 2 Contusions can lead to delayed rupture of the gallbladder via local ischemia caused by hematoma, resulting in necrosis and subsequent rupture days to weeks after the initial traumatic insult.1, 2 When gallbladder rupture occurs, there is extravasation of bile generating the “choleperitoneum.”3 Sterile bile does not produce immediate signs of peritonitis and is well-tolerated for 36 hours to several weeks until the presence of peritonitis secondary to chemical irritation or infection.3 Gallbladder rupture is difficult to diagnose; therefore, patients may return to the hospital after discharge with jaundice, abdominal discomfort or distension, and even peritonitis.1, 2 Treatment is traditionally by cholecystectomy. Cholecystorrhaphy, cholecystostomy, and endoscopic biliary stent placement have been performed successfully.1, 2 Treatment depends on the severity of the damage and the general condition of the patient.1, 2 Our patient was treated by percutaneous drainage alone. Four weeks later, repeat nuclear medicine scan showed the leakage had disappeared. He has remained symptom-free over the ensuing year since drainage removal.

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References 

  1. Sharma O. Blunt gallbladder injuries: presentation of twenty-two cases with review of the literature. J Trauma. 1995;39:576–580
  2. Sugiyama M, Abe N, Masaki T, et al. Endoscopic biliary stent placement for treatment of gallbladder perforation due to blunt abdominal injury. Gastrointest Endosc. 2000;52:275–277
  3. Greenwald G, Stine RJ, Larson RE. Perforation of the gall bladder following blunt abdominal trauma. Ann Emerg Med. 1987;16:452–454

 Conflicts of interest The authors disclose no conflicts

 For submission instructions, please see the Gastroenterology web site (www.gastrojournal.org).

PII: S0016-5085(09)01881-2

doi:10.1053/j.gastro.2009.07.081

Gastroenterology
Volume 138, Issue 4 , Page 1250, April 2010

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