Subtle Signs Of Gallbladder Perforation: A Missed Diagnosis On Initial Imaging – Case Series

Abstract

Background: Gallbladder perforation (GBP) is a rare but potentially fatal complication of acute cholecystitis. Early diagnosis is challenging due to its nonspecific presentation and subtle imaging findings, often leading to missed diagnoses on initial evaluation. Timely detection on imaging is critical to guide prompt surgical intervention and improve outcomes.

Aim: To present a case series highlighting subtle radiological signs of GBP that were overlooked on initial imaging, emphasizing the importance of high suspicion in at-risk patients.

Methods: A Case Series was conducted in the Department of Radiodiagnosis over 1.5 years, including 10–15 patients with surgically or histopathologically proven gallbladder perforation whose initial imaging (ultrasound and/or CT) did not clearly suggest perforation. Clinical records, laboratory data, and imaging studies were reviewed. Subtle findings such as focal gallbladder wall defect, pericholecystic fluid, localized fat stranding, and perihepatic collections were identified and correlated with intraoperative findings.

Results: The majority of cases presented with vague right upper quadrant pain and nonspecific laboratory findings. Initial ultrasonography often showed gallbladder wall thickening and cholelithiasis without overt signs of perforation. Retrospective review revealed subtle indicators such as:

• Discontinuity of gallbladder wall in focal areas
• Small, loculated pericholecystic collections
• Unexplained adjacent hepatic hypoechoic areas or fluid pockets
• Minimal pneumoperitoneum on CT Missed recognition of these signs delayed diagnosis by an average of 24–72 hours.

Conclusion: Gallbladder perforation can have subtle imaging clues, especially in its early stages. Radiologists must maintain a high index of suspicion in elderly patients, diabetics, and those with severe cholecystitis, even when classic signs are absent. Careful scrutiny of gallbladder wall integrity, adjacent fluid, and subtle perihepatic changes can aid early detection, prevent morbidity, and guide timely surgical management.