DOI:10.2214/AJR.04.1637
AJR 2005; 185:1573-1574
© American Roentgen Ray Society
CT Diagnosis of Traumatic Gallbladder Injury
Aaron Wittenberg and
Anthony J. Minotti
Department of Radiology, MetroHealth Medical Center, 2500 MetroHealth
Dr., Cleveland, OH 44109.
Received October 20, 2004;
accepted after revision December 6, 2004.
Address correspondence to A. Wittenberg
(aaronwittenberg{at}yahoo.com).
Introduction
Isolated traumatic gallbladder injuries are uncommon and difficult
to diagnose. Motor vehicle collision is the most common cause of gallbladder
injury [1]. Two percent of
patients who undergo laparotomy for traumatic injury are found to have a
gallbladder injury [2].
Clinically, a patient with traumatic gallbladder injury will develop slowly
progressive abdominal complaints. Less frequently, traumatic gallbladder
injury presents as an acute abdomen. Therefore, clinical signs and symptoms
are not always helpful in diagnosis. The time from injury to laparotomy can
range from 3 to 7 days [3].
This delay in diagnosis causes a significant increase in the morbidity and
mortality associated with traumatic gallbladder injuries. The spectrum of
gallbladder injuries includes wall contusion, laceration, perforation, and
avulsion [4]. The diagnosis can
be made most effectively with CT. Sonography may also be useful.
False-positive conditions include milk of calcium and vicarious excretion of
contrast material from previous CT studies. When the patient is undergoing
initial abdominal CT, delayed imaging through the gallbladder can be helpful
to more confidently diagnose traumatic gallbladder injury.
Case Report
A 60-year-old man was the unrestrained driver of a vehicle that was struck
on its side. Fifteen to 20 inches of intrusion into the patient's driver
compartment occurred and the steering wheel was bent, both indicators of
significant abdominal trauma. On arrival to the emergency department, the
patient was found to have a decreased mental status with grunting respirations
and was subsequently intubated. The patient's heart rate was 120 beats per
minute and blood pressure was 110 over 70 mm Hg. On abdominal examination, the
patient's bowel sounds were normal. Ecchymosis was noted across the upper
abdomen. Significant initial laboratory studies included a blood alcohol level
of 286 mg/dL; initial hemoglobin of 14.3 g/dL; and elevated hepatic enzymes
including alkaline phosphatase of 74 IU/L, alanine aminotransferase of 217
IU/L, and aspartate aminotransferase of 406 IU/L. A follow-up hemoglobin 2 hr
later was 10.6 g/dL. Preoperatively, the patient's hemoglobin had decreased to
9.7 g/dL.
A CT scan of the abdomen revealed a liver laceration near the gallbladder
fossa and dense fluid within the gallbladder lumen
(Fig. 1A). A small amount of
perihepatic free fluid was present. Delayed images of the liver and
gallbladder again showed an increased amount of dense fluid within the
gallbladder lumen (Fig. 1B).
This was thought to represent contrast extravasation within the gallbladder,
possibly secondary to a laceration of a vessel within the gallbladder
wall.
Operative findings included a partial avulsion of the gallbladder at its
vascular pedicle and a grade II liver laceration through the gallbladder fossa
with active bleeding in the gallbladder fossa. The patient's postoperative
course was uneventful.
Discussion
Severe gallbladder injury can take the form of contusion, laceration, and
avulsion. Gallbladder contusion, or intramural hematoma, is most often
diagnosed at the time of laparotomy and is thought to be underreported.
Gallbladder laceration, or rupture, is the most commonly reported gallbladder
injury [5]. The cause of
gallbladder injury arises from compressive and shearing forces, most commonly
in motor vehicle accidents. The treatment of choice is cholecystectomy.
A distended postprandial gallbladder is at increased risk for avulsion in
acceleration/deceleration mechanisms of injury, as an increased shearing force
is generated between the fluid-filled gallbladder and the hepatic parenchyma
[3]. Paradoxically, a
chronically diseased gallbladder with a thickened wall has a protective effect
against gallbladder injury. Elevated serum ethanol, as in this case, can also
increase the risk for a gallbladder injury in a trauma setting. Alcohol
increases sphincter of Oddi tone, which causes subsequent gallbladder
distention [1].
The diagnosis of gallbladder injury is made by detecting blood within the
gallbladder lumen. Using sonography, echogenic fluid will be detected within
the gallbladder. CT most confidently achieves the diagnosis of gallbladder
injury. Blood in the gallbladder most reliably presents as high-density fluid
within the gallbladder lumen
[6]. Other CT findings that are
suggestive of gallbladder injury include thickening or indistinctness of the
gallbladder wall and active arterial extravasation into the lumen as shown in
Figures 1A, and
1B. Complete avulsion of the
gallbladder results in displacement of the gallbladder from its fossa.
Pericholecystic fluid and collapsed gallbladder lumen are less specific
indicators of gallbladder trauma
[7]. Associated intraabdominal
injuries include liver laceration and duodenal hematoma
[1]. Peritoneal lavage may be
negative in the setting of an isolated gallbladder avulsion injury because a
bile leak and hemorrhage from a ruptured gallbladder may be contained within
the extraperitoneal gallbladder fossa
[4].
IV contrast administration normally causes gallbladder wall enhancement if
the arterial supply is intact
[8]. Vicarious contrast
excretion, cholelithiasis, and milk-of-calcium bile also appear as hyperdense
material within the gallbladder lumen on CT and can be confused with
gallbladder injury. Delayed imaging can be useful in differentiating true
gallbladder hemorrhage from other nontraumatic gallbladder findings. In the
setting of gallbladder trauma, delayed images will show an increased amount of
dense fluid within the gallbladder as hemorrhage progresses. Conversely,
nontraumatic gallbladder findings will remain stable on the delayed images. In
the case presented, an increased amount of high-density fluid was present
within the gallbladder on the delayed images compared with the initial images.
Also, a definite fluid-fluid level had formed on the delayed images.
Gallbladder injuries, while infrequent, can be difficult to diagnose. CT is
the most reliable technique to diagnose a gallbladder injury. However, benign
entities can mimic gallbladder injury. Delayed images through the gallbladder
can be useful in differentiating between a true gallbladder injury and a
relatively benign process.
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Introduction
Case Report
