CT Diagnosis of Isolated Intramural Dissection of the Gallbladder Wall Following Blunt Abdominal Trauma

Case Report

Austin J Radiol. 2017; 4(2): 1068.

CT Diagnosis of Isolated Intramural Dissection of the Gallbladder Wall Following Blunt Abdominal Trauma

Benagiano G¹*, Mori S², Paolucci ML¹, Semeraro A3, Colucci F4, Dedola GL¹ and Santini S5

¹Department of Radiology, San Giovanni di Dio Hospital, Florence, Italy

²Department of Surgery, San Giovanni di Dio Hospital, Florence, Italy

³Department of Radiology, Meyer Hospital, Italy

4Department of Radiology, San Camillo Forlanini Hospital, Rome, Italy

5Department of Radiology, San Giuseppe Hospital, Empoli, Italy

*Corresponding author: Benagiano G, Department of Radiology, San Giovanni di Dio Hospital, No 3 Torregalli Road, Post Code 50143, Florence, Italy

Received: July 03, 2017; Accepted: August 01, 2017; Published: August 11, 2017


The gallbladder is rarely injured in blunt abdominal trauma due to its small size and anatomical protection by the surrounded liver, omentum and ribcage. Blunt gallbladder injuries are usually associated with damage of adjacent abdominal organs. Isolated gallbladder injury is an even more infrequent occurance. The diagnosis may be difficult and often delayed due to variable and non-specific clinical signs and symptoms, potentially increasing in the morbidity and mortality associated with traumatic gallbladder injuries. Prompt diagnosis is thus essential but represents a challenge. Of all imaging modalities, Computed Tomography (CT) is the most effective diagnostic tool for early identification of traumatic gallbladder injuries facilitating surgical planning and management. We present the first case of isolated intramural dissection of the gallbladder wall secondary to blunt abdominal trauma which was diagnosed by CT and subsequently confirmed by cholecystectomy.

Keywords: Gallbladder; Traumatic intramural dissection; Abdominal blunt trauma; Computed tomography (CT)

Case Report

A 48-year-old male with a history of chronic alcohol abuse, was admitted to the emergency department after crashing against a cemented wall with a car. On admission the patient referred right upper quadrant pain and was hemodynamic ally stable with blood pressure of 160/80 mmHg and pulse rate of 73/min. On physical exam there was right upper abdominal tenderness with positive Murphy’s sign. Laboratory studies revealed a blood alcohol level of 2.28 g/L, alanine Aminotransferase (ALT) of 395 UI/L, aspartate Aminotransferase (AST) of 630 UI/L, Lactate Dehydrogenase (LDH) of 614 U/L. Initial hemoglobin level was 14.9 g/dL. A FAST (Focused Assessment with Sonography in Trauma) examination revealed a distended gallbladder with wall thickened and pericholecystic fluid. Therefore a subsequent Computed Tomography (CT) was performed. Unhanced CT demonstrated marked enlargement of the gallbladder (measuring 15 x 6 x 7.5 cm) with hyper dense intraluminal fluid compatible with blood (Figure 1A), estending into and distending the gallbladder neck and cystic duct. On contrast enhanced phase the gallbladder showed active arterial intraluminal extravasion, a site of mucosal discontinuity and a double-contour thickening of the anterior wall with evidence of a dissection flap (Figure 1B,C). Additionally a small amount of pericholecystic and perihepatic fluid was noted. Delayed images revealed an increased amount of intraluminal hyper density (Figure 1D) with fluid-fluid level as hemorrhage progress (Figure 1E). No evidence of other intraperitoneal injuries was noted. Therefore, the diagnosis of isolated gallbladder wall injury was considered based on imaging findings. After observation of 10 hours the patient complained of persistent right upper abdominal pain. Hemoglobin level decreased to 12.6 g/dL and the onset of melena was noted. Exploratory laparotomy revealed a grossly enlarged gallbladder with intact serosa that showed a large subserosal ecchymosis on the anterior wall (Figure 2). A small amount of hemoperitoneum was present and no evidence of free bile in the peritoneal cavity and other abdominal injuries was observed. After abdominal wash, cholecystectomy was performed and an abdominal drain was placed. Postoperative course was uneventful and patient was discharged on the 8th postoperative day. Upon opening the gallbladder postoperatively, an intramural hematoma between the layers of the anterior wall was present and the gallbladder lumen was full of fresh blood and blood clots. After removal of intraluminal hematoma, an about 2-cm mucosal laceration of the anterior wall of the gallbladder and other small superficial mucosal tears were found (Figure 3). In conclusion, traumatic intramural dissection of the gallbladder wall with subsequent intramural hematoma was confirmed.