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Gallbladder Avulsion Due To Blunt Trauma

¹ Department of Radiology, Harborview Medical Center, University of Washington School of Medicine, 325 Ninth Ave., Box 359728, Seattle, WA 98104-2499.
² Department of Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle, WA 98104-2499.

Received March 14, 2001; accepted after revision March 14, 2001.

 
This is another in the continuing series on radiology in trauma cases from the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and Lee B. Talner.

Address correspondence to F. A. Mann.

Introduction

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A 26-year-old man, ejected during a rollover motor vehicle collision, was hemodynamically stable in the trauma center. CT showed multiple abdominal injuries (Fig. 1A,1B,1C). Laparotomy revealed liver laceration, total gallbladder avulsion with disruption at the junction of the gallbladder and the cystic duct, and laceration of the distal common bile duct near the duodenum. In addition, we found near total transection of the duodenum and right renal artery occlusive dissection. Surgical treatment included completion cholecystectomy, primary repair of the duodenum with pyloric exclusion and gastrojejunostomy, repair of the distal common bile duct injury, and right nephrectomy.

View larger version (125K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1A. —Contrast-enhanced helical CT scans in 26-year-old man with gallbladder avulsion and multiple associated major abdominal injuries resulting from motor vehicle crash. Image reveals grade 3 liver laceration.

View larger version (106K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1B. —Contrast-enhanced helical CT scans in 26-year-old man with gallbladder avulsion and multiple associated major abdominal injuries resulting from motor vehicle crash. Scan shows complete transection of proximal duodenum (arrow) and intact wall of gastric antrum (arrowheads). Note nonperfusion of right kidney.

View larger version (102K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1C. —Contrast-enhanced helical CT scans in 26-year-old man with gallbladder avulsion and multiple associated major abdominal injuries resulting from motor vehicle crash. Scan shows gallbladder wall thickening and focal hematoma with intraluminal bile—blood level. Massive pneumoperitoneum outlines falciform ligament. Small amount of contrast material has refluxed from IV cholangiography into hilar portion of right renal vein.

Discussion

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Gallbladder injury occurs in 2% of blunt trauma victims [1], the low incidence being attributed to the organ's well-protected location. Most blunt gallbladder injuries result from motor vehicle crashes, falls, and kicks or blows to the abdomen [1]. Factors predisposing to blunt gallbladder injuries are a thin-walled normal gallbladder, a distended gallbladder, and alcohol ingestion, which increases sphincter of Oddi tone and biliary tract pressure [1].

Blunt gallbladder injuries are classified as contusion, perforation, and avulsion [1, 2]. Contusion, defined as intramural hematoma, is most often diagnosed at the time of laparotomy and is probably underreported. Perforation, also known as "rupture" or "laceration," is the most commonly reported injury. Avulsion, the second most commonly reported injury, has three subtypes: partial avulsion, in which the gallbladder is partially torn from the liver bed; complete avulsion, in which the gallbladder is completely torn from the liver bed but with intact cystic duct and artery; and total avulsion, in which the gallbladder lies free in the abdomen, torn from all attachments. To our knowledge, only seven cases of total avulsion (also called "traumatic cholecystectomy") have been reported [1,2,3,4]. Traumatic cholecystitis is caused by cystic duct obstruction by blood clots from liver or gallbladder injury.

Associated intraabdominal injuries are common in patients with blunt gallbladder injury, averaging 2.7-3.3 associated injuries per patient [1]. Liver injury is especially likely, with a reported incidence of 83-91%. Duodenum and spleen injuries occur in up to 54% of patients with blunt gallbladder injury [1]. Our patient had three associated injuries: to the liver, to the duodenum, and to the kidney.

CT findings of gallbladder injury are largely nonspecific [3, 4]. Pericholecystic fluid is most common but least specific. Other signs of gallbladder injury are ill-defined contour of gallbladder wall, mass effect on duodenum, high-attenuation intraluminal material (blood), thickened gallbladder wall, and collapsed gallbladder in a fasting patient. Furthermore, major liver injury often dominates the CT picture and over-shadows subtle abnormalities of the gallbladder. It is not surprising that unsuspected gallbladder injury is often discovered during laparotomy for coexisting intraabdominal injuries [1].

Choice of treatment depends on the severity of the gallbladder injury and the general condition of the patient. Patients with mild injuries such as contusion or isolated partial avulsion may be observed, although late necrosis and perforation have been reported [1]. Severe injuries generally require cholecystectomy. Cholecystostomy may be used to temporize in unstable patients or poor operative candidates.

References

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1. Sharma O. Blunt gall bladder injuries: presentation of twenty-two cases with review of the literature. J Trauma 1993;39:576 -580
2. Losanoff JE, Kjossev KT. Complete trauma avulsion of the gallbladder. Injury 1999;30:365 -368[Medline]
3. Erb RE, Mirvis SE, Shanmuganathan K. Gall bladder injury secondary to blunt trauma: CT findings. J Comput Assist Tomogr 1994;18:778 -784[Medline]
4. Jeffrey RB Jr, Federle MP, Laing FC, Wing VW. Computer tomography of blunt trauma to the gall bladder. J Comput Assist Tomogr 1986;10:756 -758[Medline]

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