# Unexpected peritonitis: Spontaneous gallbladder perforation without prior cholecystitis in an elderly patient - A case report

## TL;DR

A 76-year-old man with no gallbladder history developed peritonitis from a spontaneous gallbladder perforation, highlighting the need for timely imaging and surgery in elderly patients.

## Contribution

This case report highlights the rare occurrence of spontaneous gallbladder perforation without prior cholecystitis and emphasizes the importance of early diagnosis and treatment in elderly males.

## Key findings

- Spontaneous gallbladder perforation is rare and often presents as acute peritonitis in elderly males.
- Contrast-enhanced CT is more accurate than ultrasound for detecting gallbladder perforation features.
- Emergency cholecystectomy is the main treatment for Type 1 perforation with peritonitis.

## Abstract

Gallbladder perforation is a rare but serious complication, usually following acute cholecystitis. Spontaneous perforation without prior biliary symptoms is extremely uncommon and often presents as acute peritonitis, especially in the elderly and/or immunocompromised patients. Early diagnosis and prompt surgical intervention are essential to reduce morbidity and mortality.

A 76-year-old male with no prior history of gallbladder disease presented with a 3-day history of right upper quadrant pain and signs of generalized peritonitis. Imaging revealed a perforation in the gallbladder fundus with pericholecystic fluid and intraluminal stones. Emergency laparotomy confirmed a 5 mm fundal perforation with 500 ml of bile-stained peritoneal fluid. Cholecystectomy and peritoneal lavage were performed. The patient recovered uneventfully.

Spontaneous gallbladder perforation is rare, especially without prior cholecystitis. It most commonly occurs at the fundus due to its limited blood supply, making it susceptible to ischemia. While cholecystitis is more frequent in females, perforation is more common in elderly males. Clinical signs may be nonspecific, and perforation is often diagnosed only via imaging or intraoperatively. Contrast-enhanced computed tomography is the most sensitive imaging modality, identifying mural defects, pericholecystic fluid, and fat stranding. Laparoscopic or open cholecystectomy with peritoneal lavage remains the mainstay of treatment.

Spontaneous gallbladder perforation should be considered in elderly patients with an acute abdomen, even without a history of gallbladder disease. Timely imaging and surgical management are vital for favorable outcomes. Early recognition, appropriate classification, and individualized treatment planning can significantly reduce complications and improve long-term prognosis.

•Spontaneous gallbladder perforation without prior cholecystitis is rare, symptoms are nonspecific, often in elderly males.•Gallbladder fundus is the commonest site for perforation, leads to Type 1 (Niemeier) perforation with biliary peritonitis.•Contrast-enhanced computed tomography has high accuracy than ultrasound in detecting mural defects and pericholecystic fluid.•Emergency open cholecystectomy is preferred for Type 1 perforation, especially with bile peritonitis and sepsis.•Laparoscopic or percutaneous drainage may be options in stable patients, but delayed cholecystectomy is often needed.

Spontaneous gallbladder perforation without prior cholecystitis is rare, symptoms are nonspecific, often in elderly males.

Gallbladder fundus is the commonest site for perforation, leads to Type 1 (Niemeier) perforation with biliary peritonitis.

Contrast-enhanced computed tomography has high accuracy than ultrasound in detecting mural defects and pericholecystic fluid.

Emergency open cholecystectomy is preferred for Type 1 perforation, especially with bile peritonitis and sepsis.

Laparoscopic or percutaneous drainage may be options in stable patients, but delayed cholecystectomy is often needed.