Laparoscopic cholecystectomy after isolated blunt gallbladder trauma resulting in intraluminal hemorrhage: computed tomography and operative findings.

Traumatic hemorrhagic cholecystitis is a rare occurrence. Most reported cases of gallbladder trauma, including laceration/perforation, avulsion, and contusion/hemorrhage, to date have been managed with laparotomy. We report a case of intraluminal hemorrhage after blunt abdominal trauma managed laparoscopically, highlighting imaging and operative findings. The patient is a 43-year-old woman who was leaving the attic of a second story home when she fell from a roof approximately 15 feet to the ground on the morning of admission. She was brought to our hospital for evaluation. She was always hemodynamically normal. Her serum ethanol was 213 mg/dL. On examination, she was awake and alert. She had mild right upper quadrant tenderness. She was taken for computed tomography (CT) of her chest, abdomen, and pelvis. This showed right second to fourth rib fractures and a right pneumothorax. Also noted were a thickened gallbladder wall, marked pericholecystic fluid, and suspected hemorrhage into the gallbladder (Fig. 1). The abdominal CT was otherwise negative. A right chest tube was placed and the patient under-went diagnostic laparoscopy, and a markedly distended and inflamed gallbladder filled with blood was found (Fig. 2). The gallbladder was successfully removed laparoscopically without complication. The patient had an uneventful recovery, was sent home several days later, and was asymptomatic on outpatient follow-up 3 weeks later. Fig. 1 Axial enhanced computed tomography scan in the pyelographic phase demonstrating marked thickening of the gallbladder wall, enhancing mucosa, and focal hyperdensity in the gallbladder lumen that was not present during the corticomedullary phase, concerning ... Fig. 2 Intraoperative photograph showing a massively distended and inflamed gallbladder filled with blood. Injury to the gallbladder is rare, occurring in approximately 2 per cent of all patients with blunt abdominal trauma,1 and the diagnosis may be elusive. A delay in diagnosis may lead to serious morbidity. Nearly 100 per cent of cases will have associated intra-abdominal trauma,2 so a case like this without other such abdominal injuries is rare. The gallbladder is relatively protected from external trauma as a result of its position under the liver and is also surrounded by intestine and omentum, so in the absence of other injuries, gallbladder trauma is unusual. The test most commonly used to evaluate any stable patient with blunt abdominal trauma is CT. Findings on CT that suggest blunt injury to the gallbladder are pericholecystic fluid, ill-defined gallbladder wall contour, high-density intraluminal content, thickening of the gallbladder wall, and a collapsed gallbladder lumen.3 Of these, pericholecystic fluid is most commonly found. Such injuries are uncommonly reported, but most have been managed with laparotomy. Because laparoscopy is used in most elective cases when cholecystectomy is necessary, it would seem logical to extend its use to the trauma patient with hemorrhagic cholecystitis. Laparoscopic cholecystectomy has also been reported after rupture of the gallbladder as a result of blunt abdominal trauma.4 Injuries to the gallbladder may result in laceration or perforation, avulsion from the liver bed, and, least commonly, traumatic contusion, like in this case, with an intraluminal hematoma that may progress to wall perforation days to weeks later if the diagnosis is not made.2 As we re-port, injuries such as this may be managed laparoscopically, thus avoiding the morbidity of trauma laparotomy.