Introduction
The abdomen is the third most commonly injured anatomic region followed by the head
and extremities [1 ]. Children are more prone for intraabdominal injuries for several reasons. Firstly,
the organs are less protected due to children having less fat and weaker muscles.
Secondly, the ribcage offers less protection due to its increased limberness [2 ]. Furthermore, the smaller body size allows for a greater distribution of injury.
Hence, children often suffer multiple traumatic injuries in several regions. Therefore,
clinicians must maintain a high index of suspicion in cases of specific injury mechanisms
or patterns such as bicycle handlebars in order to detect subtle abdominal injuries.
When examining those posttraumatic patients, the possibility of gallbladder perforation
must be kept in mind.
We present a case of gallbladder perforation after blunt abdominal trauma in which
imaging modalities such as ultrasound and magnetic resonance imaging (MRI) helped
us to determine the proper management. Moreover, a systematic review of the recent
literature was performed using PubMed and Google Scholar as databases.
Methods
A review of the literature was performed by online search in PubMed and Google Scholar
using “traumatic gallbladder injury in children”, “traumatic gallbladder perforation
children”, “blunt abdominal trauma children” as keywords. Articles with other extrahepatic
biliary injuries as well as other causes of gallbladder perforation such as spontaneous
or secondary to an underlying disease were excluded. Furthermore, we searched for
cases with isolated traumatic gallbladder injury, comparable to our case. The literature
from the period 2000 to 2020 was evaluated.
Case Report
An 8-year-old male patient was admitted to pediatric emergency for abdominal trauma
due to a handlebar injury. The child fell from his bicycle and landed with his upper
right abdominal quadrant on the handle of his bike. Physical examination revealed
severe upper right abdominal pain, general pale skin color, and a bruise of 3 cm × 3 cm
located in the right upper abdominal quadrant with diffuse abdominal pain on palpated.
Initial Focused Assessment with Sonografy for Trauma (FAST) presented ubiquitous intraperitoneal
fluid and irregular reflection of the liver with an inhomogeneous area at the right
part. Furthermore, a hyperechogenic structure was pictured at the gallbladder’s location.
Laboratory analysis unveiled a slight rise in liver enzymes (aspartate aminotransferase
(AST): 86 U/l; alanine aminotransferase (ALT): 55 U/l) and regular hemoglobin level
(13.1 g/dl). Considering the trauma, clinical presentation, and sonografic findings,
liver laceration and gallbladder hematoma was the presumptive diagnosis.
Because of increasing paleness, hypotension, tachycardia, a 3-point drop in hemoglobin,
as well as general deterioration and vomiting, abdominal ultrasound was repeated and
showed echogenic material in and outside the gallbladder with discontinuation of the
wall at the fundus and an increased amount of intraperitoneal fluid, interpreted as
progressive intraabdominal hemorrhage ([Fig. 1 ]). Emergent magnetic resonance imaging (MRI) followed ([Fig. 2 ]), validating the laceration of the 4th liver segment, the discontinuation of the gallbladder wall, and perihepatic blood
pooling adjacent to the gallbladder. With increasing concern regarding a gallbladder
rupture, laparoscopic exploration was conducted. After extraction of approximately
1.5 l intraperitoneal blood, a perforation (1.5 cm × 1.5 cm) of the gallbladder fundus
with active, pulsatory bleeding could be seen ([Fig. 3 ]). Adjacent liver tissue was torn as well. Laparoscopic cholecystectomy and extensive
blood staunch management was performed ([Fig. 4 ]). On the 6th postoperative day, his condition stabilized sufficiently for discharge. A follow-up
after four weeks showed full remission. The high-echogenic structure located at the
gallbladder’s base was no longer visible on abdominal sonografy.
Fig. 1 B-mode ultrasound images in an 8-year old boy at the level of the gallbladder using
a linear transducer (ML6–15). a The arrow marks the small parenchymal laceration in liver segment 4 above the gallbladder.
Note the intraluminal echogenic material suggesting hematoma inside the gallbladder
(arrowhead). b Left image: A discontinuation of the gallbladder wall can be assumed at the gallbladder
fundus. Right image: Same as left image but with schematic drawing: the dashed line
(right image) marks the implied discontinuation.
Abb. 1 B-Mode-Ultraschallbilder eines 8-jährigen Jungen auf Höhe der Gallenblase mittels
eines Linearschallkopfes (ML6–15). a Der Pfeil markiert die schmale parenchymatöse Lazeration des 4 Lebersegments über
der Gallenblase. Intraluminales, echoreiches Material deutet Hämatom innerhalb der
Gallenblase an (Dreieck). b Linke Abbildung: Eine Unterbrechung der Gallenblasenwand im Bereich des Fundus lässt
sich erahnen. Rechte Abbildung: Entspricht der linken Abbildung mit zusätzlicher schematischer
Darstellung. Die gepunktete Linie markiert die angedeutete, unterbrochene Gallenblasenwand.
Fig. 2 MRI of the liver in an 8-year-old boy. Coronal T2fs weighted image a shows hyperintense fluid around the liver (three arrows) and fluid with different
signal intensities in the gallbladder bed (single arrow) suggesting hematoma. Transverse
b and sagittal c T1fs weighted images after i. v. administration of contrast media depict discontinuation
of the hyperintense wall at the gallbladder fundus wall (arrow).
Abb. 2 MRT der Leber eines 8-jährigen Jungen. Das koronale, T2fs-gewichtete Bild zeigt Flüssigkeit
um die Leber (3 Pfeile) sowie Flüssigkeit mit verschiedenen Signalintensitäten um
die Gallenblase (einzelner Pfeil) als Hinweis auf ein Hämatom. Das transversale b und sagittale c T1fs-gewichtete Bild nach i. v.-Kontrastmittelgabe lässt eine Diskontinuität der
hyperintensen Gallenblasenfunduswand erkennen (Pfeil).
Fig. 3 Laparoscopic exploration with gallbladder perforation. Exploration revealed a perforation
of 1.5 cm × 1.5 cm of the gallbladder fundus with active, pulsatory bleeding, and
massive intraperitoneal blood accumulation.
Abb. 3 Laparoskopische Exploration bei Gallenblasenperforation. Dargestellt ist eine 1,5 cm× 1,5 cm
große Perforation des Gallenblasenfundus mit aktiver, pulsatorischer Blutung. Sichtbar
ist ebenfalls die ausgeprägte intraperitoneale Blutansammlung.
Fig. 4 Postcholecystectomy. Coagulation measurements by a bipolar electrosurgical device
were performed at the gallbladder and adjacent liver tissue since the gallbladder
bed was shown to be lacerated and mildly bleeding, as well. After placement of three
clips at the cystic duct and coagulation of the arteria cystica, the gallbladder was
safely removed without further injury of the liver. Final inspection revealed no further
active bleeding.
Abb. 4 Postcholezystektomie. Es erfolgte die lokale Blutstillung mittels elektrischer Koagulation
der Gallenblase sowie des Gallenblasenbettes, da sich das angrenzende Lebergewebe
ebenfalls leicht blutend zeigte. Nach 3-facher Clippung des Duktus cysticus und Koagulation
der Arteria cystica konnte die Gallenblase problemlos ohne zusätzliche Leberverletzung
herausgelöst werden. Die abschließende Inspektion zeigte ein blutleeres Resektionsbett.
Discussion
Gallbladder injuries are rare and difficult to diagnose. Injuries of this rather small,
hollow organ is reported to be between 1.9 % and 2.1 % of all abdominal traumas and
are easily missed during initial evaluation [3 ]
[4 ]. The most commonly used classification contains contusion, laceration/perforation,
and avulsion. [5 ] Contusion, by definition, is described as the presence of intramural hematoma. Lacerations
or perforations are injuries defined as being transmural and are the most commonly
reported posttraumatic gall bladder injuries. Avulsive injuries are thought to occur
when deceleration forces are applied in the presence of a distended or full gallbladder,
as in a postprandial state. [3 ] In pediatrics, blunt trauma is the most common cause of traumatic gallbladder injury,
more specifically road traffic accidents, commonly associated with other visceral
injuries. Liver laceration is present in 83 % to 91 % of cases, with duodenal perforation
and splenic laceration in up to 50 % [4 ]. Isolated gall bladder perforation is a very rare occurrence with about 30 % of
cases in the pediatric age group [6 ]. The rare incidence is most likely because of the size and peculiar location of
the gallbladder. Lying on the under surface of the liver, it has protection from the
ribs and shock absorbance courtesy of the liver [3 ].
The low prevalence is reflected by the relatively sparse literature for this rare
condition. An online literature search for gallbladder injuries in children revealed
three original articles for the last two decades [3 ]
[7 ]
[8 ], whereas gallbladder injuries for the adult age group are quite well covered. Using
PubMed and Google Scholar as databases, only eight published case reports of gallbladder
injury in children since 2000 were identified ([Table 1 ]) [9 ]
[10 ]
[11 ]
[12 ]
[13 ]
[14 ]
[15 ]
[16 ]. In accordance with the reviewed literature, perforation was the most commonly reported
type of gallbladder injury. Only one case presented isolated gallbladder hematoma
detected by laparoscopy with conservative treatment [10 ]. Interestingly, the injury mechanism in this case, described as a fall from the
fifth floor of an apartment building, appears to be the most severe one. Despite seemingly
harmless trauma mechanisms in the other cases, perforation of the gallbladder was
eventually seen: two handlebar injuries, one injury resulting from a fall from a bicycle
with no further description, three other abdominal hits by different body parts, and
one non-traffic vehicle accident. The common element of all reported cases was the
nonspecific and vague clinical presentation on admission. All patient suffered from
diffuse abdominal pain and distended or tender abdomen. When the further course of
events is depicted, symptoms persisted or increased, similarly to our case. When mentioned,
the liver enzymes were either slightly raised or in normal range in primary survey
except for in the abovenamed case with isolated gallbladder hematoma (AST/ALT 1073/800 U/l).
Free fluid was the most common finding in abdominal sonografic examination. Akay et
al. described persistent collapsed gallbladder even after 34 hours of fasting and
advocate ultrasound re-evaluation after 6 hours of fasting for the detection of gallbladder
perforation [9 ]. In contrast, in our case the gallbladder was consistently seen to be moderately
distended. Our case differs from the others with respect to the aspect that MRI was
the advanced imaging modality for definite diagnostic identification. We decided against
computed tomografy scanning (CT) to decrease the risk of radiation and malignancy
in later life. With the presentation of gallbladder perforation, cholecystectomy was
performed in all cases, equally by laparoscopy and laparotomy. The outcome appears
to be favorable in all cases. The mean day of discharge was reported on postoperative
day 5.5 in laparotomy and 6.3 in laparoscopic intervention. However, these numbers
are not representative since two reports with laparoscopic cholecystectomy did not
indicate the day of discharge. Besides, one patient with minimally invasive treatment
who was discharged on day 11 suffered from multiple extraabdominal injuries, thus
prolonging their length of stay [10 ].
Table 1
Characteristics of cases of isolated gallbladder injury in children since 2000.
Tab. 1 Charakteristiken der Fälle mit isolierter Gallenblasenverletzung bei Kindern seit
2000.
author
type of injury
injury mechanism
clinical presentation
laboratory
diagnostic tools
management
outcome
Le et al. (2020)
(current paper)
perforation
handlebar of bicycle hit the upper right abdominal quadrant
on admission: severe upper right abdominal pain, general pale skin color, bruise of 3 cm × 3 cm
located in the right upper abdominal quadrant, diffuse abdominal pain
later on: increasing paleness, hypotension, tachycardia, 3-point drop in hemoglobin values,
general deterioration and vomiting
Hb: 13.1 g/dl
AST: 86 U/l
ALT: 55 U/l
initial FAST: ubiquitous intraperitoneal fluid, irregular reflection of the liver with an inhomogeneous
area at the right part, hyperechogenic structure at the gallbladder’s location.
follow-up ultrasound: echogenic material in and outside the gallbladder, discontinuation of the wall at
the fundus, progressive intraabdominal hemorrhage
MRI: Laceration of the 4th liver segment, discontinuation of the gallbladder wall, perihepatic
blood pooling adjacent to the gallbladder
laparoscopy and cholecystectomy
favorable outcome, discharge on the 6th postoperative day, follow-up after four weeks with full remission
Akay et al. (2008) [9 ]
perforation
hit in the right upper quadrant during a fight
on admission: severe abdominal pain, nausea, moderate epigastric tenderness, tachycardia, mild
hypotension, pyrexia
later on: abdominal tenderness and right upper quadrant pain gradually increased
Hb 9.4 g/dl
AST 47 U/l
ALT 21 U/l
initial ultrasound: small perihepatic, pericholecystic fluid collection, mild gallbladder collapse
ultrasound 24 h later: persistent collapsed gallbladder with prominent wall thickening, full-thickness tear
of the medial wall at the fundus, free fluid in peritoneal cavity, mainly around gallbladder
laparotomy and cholecystectomy
favorable outcome, discharge on the 4th postoperative day
Lin et al. (2009) [10 ]
hematoma
falling from the fifth floor of an apartment building
on admission: unconsciousness, tachycardia, mild hypotension, diffuse abdomen tenderness right>left
later on: febrile, tachycardia, persistent abdominal pain, lethargic consciousness, diffusely
tender, distended abdomen
Hb 13.4 g/dl
AST 1073 U/l
ALT 800 U/l
FAST: mild fluid accumulation in the pelvis
abdominal CT : suspected hematoma in the left lobe of the liver adjacent to the gallbladder fossa,
no free fluid in the peritoneal cavity
magnetic resonance cholangiopancreatografy : liver laceration with hematoma in the left hepatic lobe, suspected concentrated
bile in the gallbladder
laparoscopy
discharge on the 11th postoperative day, no complaints on follow-ups
Issa et al. (2017) [11 ]
perforation
bicycle handlebars hit epigastrium
on admission: diffuse abdominal pain and vomiting, no localized tenderness or abdominal distention,
hemodynamically stable and afebrile
on day 6 post-trauma: diffuse abdominal pain
Hb 12.1 g/l
AST 47 U/l
ALT 37 U/l
ultrasound: free peritoneal fluid
CT: distended gallbladder containing low-density material of mixed signal intensity consistent
with blood between the internal and external wall
repeat abdominal ultrasound and CT: dilated gallbladder with echogenic sludge and peritoneal fluid around the gallbladder
and in the Douglas space
echo-guided abdominal needle aspiration: presence of bile in the abdomen
initially: conservative (parents refused proposed laparotomy)
on day 6 post-trauma: laparotomy and cholecystectomy
no complications, discharge on the 3rd postoperative day
Jackson et al. (2016) [12 ]
perforation
non-traffic vehicle accident
on admission: tender abdomen with bruising in the epigastric region
–
CT : collapsed gallbladder with wall thickening or pericholecystic fluid, a grade II
hepatic laceration of segment 5, increased amount of free fluid in the abdomen
laparoscopy and cholecystectomy
patient progressed well, discharged on the 2nd postoperative day
Jaggard et al. (2011) [13 ]
perforation
fall on scooter handlebars
on admission : hemodynamically stable, progressive lethargy and abdominal pain, full abdomen, diffusely
but mildly tender without peritonism or bruising
later on: abdomen remained full, observations were normal, apyrexial
on day three: tachycardia, abdominal distension, diffuse tenderness, no bowel sounds, right shoulder
discomfort
liver enzymes within normal limits
CT: prominent thickened loops of jejunum and ileum, free peritoneal fluid and no solid
organ injury or free air
water soluble upper gastrointestinal tract contrast study: failed to demonstrate any perforation
laparotomy and cholecystectomy
discharged on the 7th postoperative day after establishing normal enteral feeding, in a follow-up one month
later the child was well and had returned to normal activities
Kohler et al. (2015) [14 ]
perforation
mid-air collision during a rugby practice
on admission: epigastric and right iliac fossa tenderness, signs of right upper quadrant peritonitis
were not obvious, normal bowel sounds
72 hours later: jaundice, right upper quadrant peritonitis, bilirubinuria
Hb 17.4 g/dl
chest and abdominal X-ray : unremarkable
ultrasound: mobile filling defect in the lumen of the gall bladder, no liver or pancreatic injury
CT: leakage of contrast from the region of the porta hepatis into the right iliac fossa.
biliary isotope (hepatic iminodiacetic acid) scintigrafy: free intra-abdominal leakage of bile from the fundal end of the gall bladder.
laparoscopy and cholecystectomy
uneventful recovery
Ndour et al. (2013) [15 ]
perforation
knee hit on the epigastrium
(3 weeks ago)
on admission : significantly painful abdominal distension, hemodynamically stable
Hb 10.4 g/dl
abdominal X-ray: diffuse grayness
ultrasound: abundant hemoperitoneum without obvious signs of organic lesions.
guided ultrasound puncture: brownish liquid
laparotomy and cholecystectomy
uneventful post-operative phase, discharge on the 8th postoperative day
McKinley et al. (2001) [14 ]
perforation
fall from a bicycle
on admission: hemodynamically stable, tender abdomen, guarding of the upper right quadrant
–
serial ultrasound: thick-walled gallbladder, increasing intraabdominal fluid
laparoscopy and cholecystectomy
rapid postoperative recovery
Hb = Hemoglobin; AST = Aspartate Aminotransferase; AST = Alanine Aminotransferase; U/l = Unit/Liter;
g/dl = Grams/Deciliter; FAST = Focused Assessment with Sonografy for Trauma; CT = Computed
Tomografy. Hb = Hämoglobin; AST = Aspartat-Aminotransferase; AST = Alanin-Aminotransferase; U/l = Einheit/Liter;
g/dl = Gramm/Deziliter; FAST = Focused Assessment with Sonografy for Trauma; CT = Computertomografie.
Diagnosis
With potentially life-threatening advancement, good outcome requires early diagnosis
[7 ]
[17 ]. The prognosis for isolated injury of the gallbladder remains quite good since mortality
is related to associated injuries [18 ]. However, gallbladder injuries have a vague presentation. Hence, it is a challenging
diagnosis that is often incidentally made during laparotomy performed to treat other
posttraumatic abdominal lesions [4 ]
[17 ]. The diagnosis is rarely made preoperatively and is often delayed, since the onset
of symptoms may not develop acutely. In our case, imaging modalities were the leading
diagnostic tool used to make the preoperative diagnosis of liver laceration and gallbladder
contusion.
An organized and methodical approach is required in order to identify and manage injuries
in trauma patients [1 ]. As in the adult age group, the examining clinician should apply the algorithm of
Advanced Trauma Life Support to assure stable condition for any further diagnostic
measurements. The mechanism of trauma provides crucial information on the type of
injury. Road traffic accidents remain the most common cause for traumatic gallbladder
injury, often handlebar- or seatbelt-related [3 ]
[7 ]. The morbidity of handlebar injuries is frequently underappreciated, considering
that nearly one-third of these patients require surgery [19 ]. Although this trauma mechanism can occur after seemingly harmless incidents, direct
impact on the handlebars may result in more severe injuries than flipping over them
[20 ]. With patients presenting this kind of significant trauma mechanism, clinical and
radiologic assessment must dominate. Leading signs and symptoms in our case were severe
abdominal pain of the upper-right quadrant, free intraperitoneal fluid, and hemodynamic
decompensation, described as hypotension and tachycardia. Diffuse abdominal tensing,
suggesting peritonitis due to hemoperitoneum or perforation, may not always be observable.
With ultrasound being rapid, inexpensive, portable, and readily repeatable, this noninvasive
imaging modality is well suited as the initial diagnostic tool to determine further
management and diagnosis. Sonografic examination even allows imaging of the gallbladder
contusion defined as intramural hemorrhage. A thickened wall can be presented. This
kind of injury probably occurs more commonly than previously reported [3 ]. All in all, the findings of gallbladder perforation are non-specific in most cases:
pericholecystic fluid collection, thickened or discontinuous gallbladder wall, collapsed
gallbladder, and intraluminal echogenic debris due to hematoma can be seen [17 ]. FAST can detect the presence of free fluid suggestive of intraabdominal injury.
In pediatrics, the utility of FAST can be limited since less than half of children
(< 40 %) with abdominal injury present free intraperitoneal fluid. Hence, the lack
of intraperitoneal fluid should not lead to premature dismissal of intraabdominal
injury [1 ]
[21 ]. Nonetheless, sonografic examination first identified gallbladder injury in our
case. Additional to the increasing intraperitoneal fluid, the gallbladder wall could
not be differentiated at the fundus. Hematoma was found to be adjacent. We advocate
high suspicion of gallbladder perforation if the gallbladder wall displays discontinuity
or cannot be definitively differentiated. In blunt abdominal trauma, echogenic fluid
within the gallbladder should always lead to suspicion of bleeding into the lumen
[22 ].
In children and adults alike, CT is the preferred imaging modality in severe abdominal
trauma [3 ]
[12 ]
[23 ] and the most common modality for detecting gallbladder injury [24 ]
[25 ]. The presence of pericholecystic fluid strongly suggests injury to the gallbladder
[26 ]. However, the overuse of CT in stable, minimally injured children is an important
area of concern that differs from adult trauma protocols and remains highly debated
in emergency situations. Mahajan et al. claim that clinicians often obtain abdominal
CT scans in patients that are considered very low risk of injury [27 ]. A study including 20 667 pediatric trauma patients revealed that children managed
at adult trauma centers were 1.8 times more likely to receive whole-body CT imaging
with the associated increased risk of radiation without a difference in clinical outcomes
[28 ]. MRI can be used as an evaluative tool without hazardous ionization, giving additional
diagnostic benefit in terms of tissue imaging. In cases of intraabdominal fluids,
it has a particular role in revealing the underlying pathology. [3 ] In children with mild trauma who are clinically stable, imaging without radiation
exposure should be preferred to minimize the risk of subsequent malignancy [29 ]. Presently, MRI is not established in the setting of acute abdominal trauma in most
centers. With newer, less time-consuming protocols, emergent MRI has the potential
to achieve more acknowledgement.
More recently, contrast-enhanced ultrasound (CEUS) has been developed with a diagnostic
accuracy for detecting solid organ injuries comparable to that of CT. [30 ] As stated above, it is not always possible to rule out the presence of parenchymal
traumatic lesions by sonografic examination since free intraperitoneal fluid is not
always present [21 ]. CEUS, using second-generation contrast agents which remain intravascular, has the
capability of providing a more detailed description of lesion size, the extension
to the solid organ capsule, and the presence of vascular injuries [30 ]. A solid organ injury is unveiled as a perfusion defect. Lacerations are visualized
as a hypoechoic area with an irregular border and can be associated with capsular
discontinuity. Given the contrast agents attributes, active bleeding of the gallbladder
can be detected as extravasation of hyperechoic bubbles into the peritoneal space
[31 ]. The visualization of the hyperechoic microbubbles within the gallbladder wall allow
a more accurate visualization of the gallbladder wall, ultimately resulting in higher
certainty in the identification of discontinuity or rupture. Since the contrast agent
is breathed out by the lungs (laboratory testing prior to examination (i. e. kidney
function) not required) and there is no ionizing radiation, CEUS is much more suited
for initial examination as well as for follow-ups in trauma with conservative management
in the pediatric patient [31 ]. However, the second-generation contrast agents are still off-label in children
although several multi-centric studies have already demonstrated safety in pediatric
populations [32 ]
[33 ].
Gallbladder perforations frequently cause increased hepatic enzymes, particularly
the transaminases. Nonetheless, the usefulness of elevated transaminases to predict
clinically significant liver injury as a potential screening tool for imaging is debatable.
Several cut-off values for liver injury have been introduced in the literature. With
AST/ALT levels at 86/55 U/l during the first evaluation and 176/135 U/l approximately
20 hours later, the transaminase levels of our patient never exceeded the commonly
used cut-off values for liver injury. The same applies to most of the other case reports.
However, lowering the thresholds of AST/ALT guidelines could lead to unnecessary CT
scans for children [36 ]. Since normal transaminase levels do not exclude gallbladder injury, the general
usefulness of laboratory testing is limited. Although anemia is an obvious predictor
of hemorrhage, hemoglobin and hematocrit levels were found to be normal during primary
survey in our case. Initial testing of hemoglobin and hematocrit is recommended in
the evaluation of patients with pediatric abdominal trauma, but is not a good indicator
of the need for additional imaging studies [20 ].
All in all, the leading indications which finally led us to proper diagnosis were
clinical presentation and imaging modalities, with special emphasis on ultrasound.
In our case, persistent abdominal pain after blunt trauma and significant deterioration
of general condition raised concerns regarding intraabdominal injuries. Ultrasound
examination right from the beginning of the diagnostic process and the repeated follow-up
in a short interval was able to detect progressive intraabdominal hemorrhage. Concerns
for a gallbladder injury were unveiled by sonografic imaging, initially interpreted
as gallbladder contusion with rising suspicion for laceration/perforation in the further
course. Emergency MRI provided the final confirmation which led us to explorative
laparoscopy; the discontinuation of the hyperintense gallbladder wall and intraluminal
accumulation of not only fluid but also blood with massive intraperitoneal ascites
suggesting perforation of the gallbladder with high suspicion of bile leakage.
Management
Instead of surgical intervention, close observation of the patient is sufficient in
most patients. Simple contusions or partial avulsions may be treated conservatively.
The hemodynamic condition of the child is the most important factor [20 ]. A surgeon must be readily available in case the patient becomes hemodynamically
unstable and requires immediate surgical intervention. Serial physical examinations
and sequential monitoring of general condition and hemodynamic stability are of highest
importance [6 ]
[7 ]. Advanced imaging modalities have reduced the necessity for laparotomy to less than
10 % following blunt abdominal trauma in children [2 ]
[37 ] and has enormously contributed to the shift from operative to non-operative management
[2, 7]. Free intraperitoneal fluid does not absolutely necessitate surgery. In case
of low energy and negligible volume, careful serial observation and imaging are a
reasonable approach. Diagnostic laparoscopy is advised in all other cases [3] and
is an excellent modality for the investigation with the benefit of simultaneous minimally
invasive treatment options. In terms of severe contusion or avulsion and perforation
of the gallbladder, the definitive procedure of choice is laparoscopic cholecystectomy
[4, 18, 25].
Conclusion
The authors advocate caution in cases of blunt abdominal trauma with intraperitoneal
free fluid and severe abdominal pain. We advise high suspicion of gallbladder perforation
if the gallbladder wall displays discontinuation or cannot be definitively differentiated
in sonografic examination. Echogenic fluid within the gallbladder should always lead
to suspicion of intraluminal bleeding. MRI is a useful diagnostic tool for the identification
and closer examination of intraabdominal injuries without the use of hazardous ionization.
We highly advocate MRI as a potential alternative to CT in the setting of acute abdominal
trauma, especially in the pediatric field. Pericholecystic fluid is a common finding
in advanced imaging modalities for gallbladder injury. Repeated clinical and imaging
examinations are mandatory since the onset of signs and symptoms may be delayed.