Ultrasonic “hole sign”: A reliable sign of perforation of the gallbladder?

Abstract

The sonographic findings of pericholecystic fluid collection are important signs in the diagnosis of perforation of gallb1adder.lp7 However, these are n o n s p e c i f i~.~~~~~~~ Recently, there were 2 case reports showing the "hole sign" in the gallbladder wall of patients with perforated gallbladder.loill We now present a case of gallbladder perforation with an internal biliary fistula associated with a communicating intramural abscess of right colon. In this case, the signs of pericholecystic fluid collection were not found. To our knowledge, the ultrasound findings of internal biliary fistula due to perforated gallbladder have not been described previously. CASE REPORTA 77-year-old known diabetic woman with cardiomegaly experienced fever, chills, intermittent right upper quadrant pain, and diarrhea for 20 days. Physical examination on admission disclosed moderate right upper quadrant tenderness and fever of 38.5" C. Laboratory investigations revealed a leucocytosis of 18,300 white blood cells per cubic millimeter, a fasting blood sugar of 220 mg%, a serum albumin of 2.7 g%, an amylase of 203 SU, and normal liver function tests. Two days later, the pain became more intense, abdominal rigidity developed and fever, chills, and rigor persisted despite intravenous antibiotics.In longitudinal scanning, dynamic image ultrasonography of the abdomen with a 3.5-MHz transducer revealed a distended gallbladder with a gallstone, multiple linear nonshadowing intraluminal echoes, a positive sonographic Murphy's sign and irregularities, and indistinctness of inner margin of gallbladder wall (Figure 1).In an oblique scan, there was a perforation in the fundus of gallbladder connected to the anterior aspect of an elliptical fluid collection with a fine irregular wall and internal echoes in the right middle abdomen, between which a crescent-shaped, nonpulsatile, anechoic tubular lesion was seen, suggesting the possible site of an internal biliary fistula (Figure 2). This fluidfilled collection in a right longitudinal scan, was identified as being inside the colon wall on the basis of haustral markings surrounding it.There was an echogenic beak connecting the elliptical fluid collection and the peristaltic lumen of bowel on the medial side of the disrupted abscess wall. Compression of bowel squeezed

Haemoperitoneum secondary to intrahepatic gallbladder perforation

“…However, the rapid clinical deterioration in this case prompted a CT for added detail and efficiency. There are no pathognomonic signs for gallbladder perforation on CT. A ‘hole-sign’ finding on ultrasound has been described, but this is thought to be uncommon 8. If CT findings suggest cholecystitis associated with pericholecystic fluid collection, high-attenuation intraluminal density, gallbladder wall defect, streaky omentum, gallbladder fossa haematoma, intrahepatic haemorrhage or the presence of extraluminal gallstones, all of these should raise suspicion of gallbladder perforation with possible haemorrhage 6 9…”

Sonographic diagnosis of a small fistulous communication between a subphrenic abscess and a perforated duodenal ulcer

“…In cases of gastrointestinal perforation, sonography with its multiplanar and dynamic imaging abilities has been reported to be useful for identifying colovesical fistulas and internal fistulous tracts from the gallbladder, even when small. [4][5][6] In cases of abdominal abscesses, the identification of a fistula is helpful not only in clarifying the site of perforation and etiology of the abscess but also in the subsequent management of the fistulous tract. 7 The CT demonstration of extravasation of oral contrast material is diagnostic of an enteric fistula, but the presence of an underlying fistula connecting to an abdominal abscess may not be predicted on the basis of CT alone.…”