We analyze both cases:
CASE 1
The first one was a 16 years old female with frontal car collision.
Was hemodynamically stable,
with diffuse abdominal mild pain.
The CT Gallbladder findings were pericholecystic fluid,
ill-defined walls with doubtful absence of little segment and hyperdense content. Was orientated as a contused Gallbladder with possible rupture of a little segment next to the neck.
(Fig.
1 and Fig.
2)
Other abdominal lesions were liver and spleen laceration,
and suprarenal and renal contusions. Neither chirurgical treatment was required for them.
Laparotomy was done to determine gallbladder perforation,
demonstrating integrity of the wall.
No cholecystectomy was done.
We controlled twice the integrity of the wall with ultrasonography (Fig.
3) in hospitalization revealing no lesion of it before discharge 9 days after.
CASE 2
The second one was a 72 years male with frontal car collision with high alcohol blood level.
The patient was hemodynamically unstable requiring high doses of vasoactive drugs.
Gallbladder CT findings were: hyperhenacement of the gallbladder wall,
with multiples segments of wall discontinuity and a wrinkled and collapsed gallbladder.
No active contrast extravasation was found surrounding the Gallbladder.
There was abundant pericholecystic and intraperitoneal fluid.
(Fig.
4 and Fig.
5)
Moreover the patient had massive rib affection with severe ribcage deformity and many splenic and hepatic lacerations.
Laparatomy showed an ischemic wall of the gallbladder with,
with bile leak (Fig.
6).
The surgeons found a thrombus on the cystic artery.
There was no evidence of hemoperitoneum.
A cholecystectomy was performed.
The patient died short-after going out theatre.
DISCUSION:
Although not exsiting a consensuated classification to grade the Gallbladder injury al least three situations should be described.
The first grade of Gallbladder affection is contusion.
Main findings are intragallbladder haematoma,
thickened walls and pericholecystic liquid.
Absence of wall rupture and vascular is mandatory to describe a gallbladder as contused (Fig.
1).
Conservative treatment could be done.
The second one and more severe is laceration.
Typically we should see a interruption of the wall continuity.
Loss of spherical shape as a sign of laceration should linked with previous fasting.
The third grade is vascular affection,
typically with arterial cystic avulsion,
and contrast extravasation in pericholecystic area.
Moreover,
we found that hyperenhancement of the Gallbladder walls should be linked with ischemic changes due arterial thrombosis.
On the laceration and vascular affection cholecystectomy is required.
The classical CT findings of lesion of the gallbladder assessed with evaluation of the thickness of the wall,
gallbladder shape and content,
and the presence of pericholecystic fluid.
For the presence of active bleeding the cystic artery is evaluated.
The evaluation of every parameter of Gallbladder injury helps to face the treatment.
Laparotomy is imperatively performed when perforation of the wall or vascular involvement is suspected and cholecystectomy if is confirmed.
Note the alcoholic antecedent on the second case on hyper tone of Oddi's sphincter.
The vascular involvement of the Gallbladder on traumatic event should be separated between avulsion and thrombosis.
On the one hand the section of the artery produces active bleeding,
in which the contrast spilling is the main finding.
On the other hand the thrombosis of the artery produces ischemic changes on the wall with no active bleeding. The CT vision of a thrombosis on cystic artery is considered really difficult because of itself smallness and CT resolution.
While the evaluation of active bleeding is well-described,
nor is for ischemic because of thrombosis of cystic artery. It produces a congestive Gallbladder with increased enhancement of the walls due of ischemia.
Evaluation of…
|
Findings suggesting Gallbladder involvement…
|
Wall
|
Thickness,
ill-defined,
discontinuity
|
Shape
|
Collapsed / wrinkled on fasting patient
|
Liquid arround
|
Presence of pericholecystic fluid (bile).
|
Gallbladder Content
|
Hyperdense (intragallbladder haematoma)
|
Active Bleeding
|
Active extravasation from avulsion of the cystic artery.
|
Arterial Cystic Thrombosis
|
Increased enhancement of the wall.
|