Acute Cholecystitis with intrahepatic perforation of GB causing secondary liver abscess

Above image shows distended gall bladder with pericholecystic fat stranding (orange arrow) consistent with acute cholecystitis.

Above post contrast CECT portal venous phase images showed focal small defect (yellow arrow) in the GB wall suggesting GB perforation, with abscess formation in segment V of right lobe. Blue arrow points to a single calculus within the GB lumen.

Serial axial sections showing small air pocket (orange arrow) within the liver, with adjacent heterogenous hypodense areas (yellow arrow),  superior to the hepatic abscess in segment V. If looked carefully complete pancreatic atrophy, with smooth duct dilatation and intraductal calculi can also be seen, consistent with Chronic Calcific Pancreatitis.

Eventhough acute cholecystitis is a common entity, GB perforation is rare and rarer still is its intrahepatic perforation. GB perforation is commoner in males. Risk of perforation is more in acalculous cholecystitis due to sepsis and associated co-morbidities.

Obstruction of cystic duct causes increased intraluminal pressure which inturn results in impared lymphatic and venous drainage. This results in vascular impairement leading to wall necrosis and finally perforation.

Niemeier classfied GB perforations into 3 types,
Type 1: Acute : Perforation with generalized biliary peritonitis.
Type 2: Subacute : Perforation with pericholecystic abscess and localized peritonitis.
Type 3: Chronic : Perforation with cholecysto-enteric fistula (Original classification did not include intrahepatic perforation / internal fistulae).

Treatment is with antibiotics and percutaneous drainage initially, followed by interval cholecystectomy. Open drainage and cholecystectomy has also been performed.



References:

Date RS, Thrumurthy SG, Whiteside S et al. Gallbladder perforation: case series and systematic review. Int J Surg 2012; : 63–68