Gallbladder perforation, which occurs in 3–10% of cases of acute cholecystitis, is typically associated with gallbladder necrosis. It is more common in patients with gallstone impaction in the gallbladder infundibulum or neck. Persistent elevation of gallbladder pressure can lead to ischemia and necrosis of the gallbladder wall, resulting in perforation. Elderly individuals with atherosclerosis or diabetes are more prone to this condition. The most frequent site of perforation is the gallbladder fundus, followed by the neck. Three types of gallbladder perforation can be classified based on the disease progression:
Acute Type
Rapid progression of inflammation in the gallbladder before adhesions form to offer protection results in perforation and spillage of infected bile into the free peritoneal cavity. This leads to acute diffuse peritonitis with severe clinical manifestations and poor prognosis.
Subacute Type
Perforation occurs in the presence of established adhesions between the gallbladder and adjacent organs or tissues. The perforation is contained by these adhesions, leading to the formation of a pericholecystic abscess.
Chronic Type
Adhesions between the gallbladder and adjacent organs progress to the formation of a fistula. The most common type is a cholecystoduodenal fistula (accounting for approximately 70%), followed by a cholecystocolonic fistula (approximately 15%).
The diagnosis can usually be established through a combination of medical history, physical examination, and ultrasonography. Acute perforation requires emergency surgical intervention, with the surgical approach determined based on intraoperative findings. Primary cholecystectomy during the same operation is preferred whenever possible. Where resources are available, laparoscopic cholecystectomy and peritoneal drainage can be performed. In patients unable to tolerate surgery, ultrasound-guided percutaneous gallbladder drainage is an alternative. The prevention of gallbladder perforation largely depends on the prompt and appropriate management of gallbladder diseases.