Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 58

Figure 2. Cross-section of the liver through the gallbladder wall and bed. A 0.5
cm transmural perforation extends as a necrotic fistula track into a large hematoma within the right lobe of the liver. Multifocal areas of yellow parenchymal
necrosis are also evident.

At necropsy the gallbladder contained a cholecystostomy
drain. The gallbladder was distended by two large gallstones,
each measuring 4.5 cm in diameter. The stones tightly conformed
to each other and completely filled the lumen, forming a single
mass measuring 8.0 cm in length. The gallbladder wall was
diffusely thin with an average thickness of 0.2 cm. There was a
0.5 × 1.5 cm transmural defect in the anterior wall of the gallbladder with a necrotic fistula track extending into a 10 cm hematoma in the right lobe of the liver (Figure 2), which weighed
1800 g. There were multifocal areas of necrosis throughout both
lobes. The intrahepatic hematoma was contiguous with subcapsular and extracapsular hematomas over the right lobe.
Microscopica lly, acute inflammatory cells were present near
the transmural disruption, but generalized acute cholecystitis
was absent. The common bile duct was not dilated or obstructed,
and it drained freely through the ampulla. Incidental necropsy
findings included a small renal cell carcinoma of the right kidney and moderate hypertensive and diabetic nephropathy. The
patient’s body mass index was 25.8 kg/m².
DISCUSSION
Although late operative intervention is associated with
increased morbidity, mortality, intensive care unit admissions,
and prolonged hospitalization, GP is rarely diagnosed pre-

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operatively (1). There is significant clinical overlap between
acute cholecystitis with and without perforation, but findings
that suggest GP are a sudden decrease in pain intensity and
“toxic” signs in a rapidly declining patient (5, 6). Radiologic
evaluation for suspected GP often employs ultrasound initially
with subsequent CT, but no radiographic finding is absolutely pathognomonic of GP. The characteristic “hole-sign” is
rarely seen on ultrasound; however, findings of acute cholecystitis with indirect signs of complex free fluid, gallbladder
fossa hematoma, and intrahepatic hemorrhage should suggest perforation (7). Most patients with gallstones remain
asymptomatic; however, prophylactic cholecystectomy has
been recommended in patients with large gallstones due to an
increased risk for cancer (8). Lowenfels et al found the relative
risk of gallbladder cancer in patients with gallstones ≥3 cm
to be 9 times greater than in those with stones <1 cm (9). We
believe this case provides additional support for consideration
of prophylactic cholecystectomy in patients with very large
stones, since mechanical pressure by such stones probably led
to focal transmural necrosis and perforation of the gallbladder
wall in this patient.
1.
2.

3.
4.

5.

6.
7.

8.
9.

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Baylor University Medical Center Proceedings

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