Acute biliary tract disease is uncommon in childhood. Apart from bile duct perforations, spontaneous rupture of the gallbladder itself is very rare in pediatric age; all recorded cases were secondary to coexistent disease (1,2). A child presenting idiopathic gallbladder perforation (GP) is described herein.
A six-year-old boy was referred with suspicion of acute appendicitis. He complained of vomiting and abdominal pain for the last 24 hours. Axillary temperature was 38°C and the abdomen was painful and tender. Complete blood count revealed leukocytosis. Abdominal ultrasonography demonstrated moderate free intraperitoneal fluid, mainly in the right iliac fossa and pelvis. An emergency laparotomy was performed with the presumptive diagnosis of peritonitis secondary to appendicitis but there was a 500 ml bile-stained ascites. Exploration of the abdominal cavity revealed a type I (3) oval perforation (2 cm) of the gallbladder infundibulum (Fig. 1). There were no gallstones or bile duct dilatation. Cholecystectomy was then performed and the child experienced an uneventful recovery.
Histological examination did not reveal inflammatory infiltrate or any other significant alteration of the gallbladder wall. The cultures of peritoneal fluid were negative. Postoperative biliary MRI was normal. At 15-month follow-up the child continued to be well.
Gallbladder perforation (GP) is a well-recognized condition in adults, usually located at the least vascularized fundus (4,5). It has been frequently reported vaguely as spontaneous or idiopathic, but almost all cases were in fact secondary to coexistent disease such as inflammation, trauma, or obstruction (1,3,5,7). Thus, a classification of GP is needed. We propose the criteria shown in Table 1.
In children, biliary tract perforations are usually located at bile ducts, the gallbladder itself being the least common situation. There are few scattered reports of spontaneous GP in childhood; however, all recorded cases were secondary to obstruction (1,2,6,7).
Although we cannot entirely exclude a minor trauma, the present case was classified as idiopathic because comprehensive investigation did not disclose any inflammatory/infectious condition (local or systemic) or biliary tract obstruction; moreover, the location of GP at infundibulum and absence of histologic signs of ischemia did not suggest a vascular etiology. Thus, congenital weakness of the gallbladder wall could have been a potential explanation.
The diagnosis of spontaneous GP is often delayed or missed altogether, the majority being made only at surgery. Ultrasonography and computerized tomography may demonstrate abdominal fluid but lack specificity to diagnose GP, which can be easily detected on hepatobiliary scanning (HIDA or DISIDA) (2,7,8,9). Prompt recognition and early treatment are critical to prevent serious complications (2,6,8,9).
As far as we know, the present case is the first one of an idiopathic GP in children. This entity should be added to the list of causes of acute abdomen in childhood.
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