Non-operative Management of Gallbladder Perforation After Blunt Abdominal Trauma
A 64-year-old man with a background of alcoholic liver disease presented to our Emergency Department following high velocity blunt abdominal trauma. He had been driving at 60 miles/h when he lost control and car rolled-over. He was seat-belt restrained and collision air bags were deployed. He managed to self-extricated on scene. Initial management and resuscitation was in accordance with Advanced Trauma Life Support® principles.\nAdmission Computed tomography (CT) scans were reported as unremarkable. He was admitted under cardiology for further management of a fast narrow complex tachycardia, atrial fibrillation as this was the only outstanding issue. A transthoracic echocardiogram 2 days later revealed a right ventricular thrombus and he was therefore commenced on therapeutic low molecular weight heparin.\nOn day eight post-trauma, this gentleman was referred to General Surgeons for abdominal distension and mild pain. He was stable hemodynamically and clinically he was found to have a soft, distended abdomen, with localized upper peritonism. A repeat CT scan reported free fluid and a perforated gallbladder [].\nIn view of his comorbidities, the patient was considered high risk for a general anesthetic and major abdominal surgery. After multidisciplinary discussion conservative management was agreed. An endoscopic retrograde cholangio-pancreatogram (ERCP) with stent insertion was performed and a radiologically-guided intra-peritoneal drain inserted. A diagnosis of perforated gallbladder fundus was confirmed at ERCP []. Intravenous antibiotics were commenced.\nOver the next few days, the patient's condition improved. The intra-peritoneal drain was removed at day 12 post ERCP and the patient was discharged, uneventfully 35 days after the injury.\nA follow-up ERCP 2 month later revealed a normal cholangiogram with no obvious leak and no filling defects. Stents were removed and sphincterotomy performed.\nHe was reviewed at 3 months and was doing well. Magnetic resonance cholangio-pancreatogram at 12 months showed no evidence of abnormality.