Introduction

Acute gallbladder perforation is an uncommon but potentially life-threatening complication of acute cholecystitis that is associated with significant morbidity when diagnosis is delayed. Contemporary studies suggest that perforation occurs in a minority of patients with acute cholecystitis, generally reported in the range of approximately 2–10%, and is more frequently observed in elderly individuals and those with comorbidities such as diabetes mellitus or cardiovascular disease (1, 2).
The fundus of the gallbladder represents the most vulnerable site for ischemia and subsequent perforation because of its relatively limited vascular supply. Despite advances in imaging techniques, distinguishing complicated cholecystitis from early perforation remains challenging, as clinical presentation may be nonspecific, and ultrasound findings can underestimate disease severity. As a result, the diagnosis is often made intraoperatively rather than preoperatively, particularly in subacute or sealed perforations (3).
Although gallbladder perforation has been described in the literature, occult fundal perforation without definitive preoperative imaging findings remains insufficiently emphasized, particularly in high-risk elderly diabetic patients (3).
This report aims to highlight the intraoperative detection of occult fundal perforation despite imaging findings consistent with acute cholecystitis without definitive signs of perforation and to emphasize operative decision-making in high-risk patients.

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Methods
This case report was prepared in accordance with the CARE reporting guidelines. Clinical data were obtained through retrospective review of the patient’s electronic medical records, including laboratory investigations, radiological imaging, operative notes, and histopathological findings. Ultrasound studies were reviewed in collaboration with the radiology department to assess features suggestive of complicated cholecystitis or impending perforation.
Preoperative ultrasonography demonstrated features consistent with acute cholecystitis without evidence of wall discontinuity, focal defect, or localized abscess; therefore, gallbladder perforation was not suspected prior to surgery.
The decision to proceed with urgent laparoscopic cholecystectomy was based on persistent clinical symptoms, elevated inflammatory markers, and ultrasound findings. The diagnosis of sealed fundal perforation was established intraoperatively and confirmed on histopathological examination.
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. The patient also expressed satisfaction with the care received and was grateful for the timely surgical intervention.

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Case Presentation

This report discusses a patient requiring emergency surgery for acute cholecystitis with perforation. A 72-year-old diabetic male on metformin presented with a 5-day history of continuous right upper quadrant pain, nausea, and fever. He appeared dehydrated and unwell. Physical examination revealed right upper quadrant rebound tenderness, rigidity, and hypoactive abdominal sounds.
Vital signs included an axillary temperature of 38.4°C, blood pressure of 96/27 mmHg, respiratory rate of 26 breaths/min, pulse of 97 beats/min, and oxygen saturation of 98%. Laboratory investigations revealed a white blood cell count of 18.8 × 109/L, neutrophils 16 × 109/L, hemoglobin 12.9 g/dL, C-reactive protein (CRP) 270 mg/L, creatinine 1.9 mg/dL, random blood glucose 231 mg/dL, glycated hemoglobin 7.1%, International Normalized Ratio 1.34, albumin 3 g/dL, and blood urea nitrogen 37 mg/dL. Electrolytes, amylase, lipase, and bilirubin were within normal ranges.
Abdominal ultrasound demonstrated a markedly distended gallbladder measuring 11 × 4.8 × 5.5 cm, with multiple small calculi, sludge, wall thickening and edema, increased echogenicity in the gallbladder fossa, minimal pericholecystic fluid, and a positive sonographic Murphy sign, as shown in Figure 1A–C. The common bile duct was normal at 4.5 mm, as shown in Figure 2.

 

Figure 1A

Figure IB

Figure 1C

Figure 1A–C. Ultrasound findings of acute cholecystitis. (A) Gallbladder wall thickening (arrow) with mural edema and intraluminal sludge (arrowhead). (B) Gallbladder calculi (arrowheads) with posterior acoustic shadowing (arrow). (C) Minimal pericholecystic fluid adjacent to the gallbladder wall (arrow).

 

Figure 2

Ultrasound image demonstrating normal common bile duct (CBD) (arrow), portal vein (PV) with adjacent pericholecystic fluid (arrowhead).

Following resuscitation, the patient underwent emergency laparoscopic cholecystectomy due to acute cholecystitis complications. During surgery, an inflamed omentum adhered to the liver, and gallbladder was noted. The gallbladder wall was inflamed, thickened, gangrenous, and perforated at the fundus, with fibrin and bile surrounding it, as shown in Figure 3. Adhesions were lysed, the gallbladder was removed, the peritoneum was irrigated with warm saline, and a drainage tube was inserted.

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Figure 3

Intraoperative laparoscopic view showing a sealed gallbladder perforation (arrow) with localized bile leakage (arrowhead).

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Histopathology results were consistent with extensive erosive, focal necrotic/perforated, acute cholecystitis.
Postoperatively, recovery was uneventful, and the patient tolerated an oral diabetic diet. On postoperative day 4, laboratory values improved, with white blood cell (WBC) 16.3 × 109/L, neutrophils 12 × 109/L, CRP 105 mg/L, random blood glucose 145 mg/dL, and creatinine 0.8 mg/dL. Follow-up ultrasound showed minimal fluid in the gallbladder bed with increased mesenteric fat echogenicity, likely post-cholecystectomy, and amikacin was added to ongoing piperacillin/tazobactam therapy. By postoperative day 7, inflammatory markers continued to decrease (WBC 12.5 × 109/L, neutrophils 9.5 × 109/L, CRP 64.5 mg/L, creatinine 0.9 mg/dL, random blood glucose 140 mg/dL). The patient was discharged on postoperative day 10 with further improvement (WBC 6.63 × 109/L, neutrophils 4.7 × 109/L, CRP 15.9 mg/L, creatinine 1.0 mg/dL, random blood glucose 132 mg/dL). At follow-up 5 days later, the patient remained well, with normal vital signs and laboratory parameters.

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Discussion

Elderly patients, particularly males, are more prone to gallbladder perforation, especially in later decades of life. Comorbidities such as infections, steroid use, diabetes, hypertension, and malignancy are recognized risk factors for gallbladder perforation, even in the absence of gallstone disease (4, 5).
Gallbladder perforation is commonly classified according to Niemeier’s system. Type 1 represents acute free perforation into the peritoneal cavity without protective adhesions, whereas type 2 describes a subacute perforation sealed by adhesions, often resulting in localized abscess formation.
Type 3 involves a persistent perforation with fistula formation between the gallbladder and adjacent bowel, and type 4 refers to cholecysto-biliary fistula (3, 6).

The fundus of the gallbladder faces an increased risk of ischemia and necrosis because it represents the farthest point from the vascular supply of the gallbladder during cystic artery thrombosis and inflammation (3, 7). Fundal perforation is not consistently recognized as the first site of rupture, which may delay diagnosis and surgical decision-making.
The patient showed symptoms of acute cholecystitis, but the extent of tissue death and the exact perforation site became evident only intraoperatively. The detection of small fundal defects remains challenging for imaging tests, including advanced ultrasonography and computed tomography scans, before surgical intervention (6). Clinicians should maintain a high index of suspicion when inflammatory markers worsen despite inconclusive imaging.
Several reports describe gallbladder perforation in elderly diabetic patients; however, documented cases of occult fundal perforation remain limited, highlighting the diagnostic variability reported in the literature (8).

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Conclusion

Gallbladder perforation is an uncommon but serious complication of acute cholecystitis, particularly in elderly patients with significant comorbidities such as diabetes. While imaging may support the diagnosis of acute inflammation, it may underestimate the extent of necrosis or fail to reveal occult fundal perforation. This case reinforces the importance of operative judgment, as the true severity may only become evident intraoperatively, and timely surgical management is crucial to prevent progression to severe sepsis or localized abscess formation.

 

References​​

1. Cyprich J, Sandigo-Saballos I, Neville A, et al. Outcomes after early vs interval cholecystectomy for perforated cholecystitis: a multicenter cohort study. Am J Surg. 2025; 250: 116532.

2. Ausania F, Guzman Suarez S, Alvarez Garcia H, et al. Gallbladder perforation: morbidity, mortality and preoperative risk prediction. Surg Endosc. 2015; 29(4): 955-60.

3. Singh H, Chejara RK, Thippeswamy NG, et al. Decoding the enigma of gallbladder perforation: exploring patient profiles, diagnosis, and step-up management pathways. Cureus. 2025; 17(5): e84791.

4. Albisher HM, Foula MS, Alghusnah ES, et al. Risk factors and outcomes in acute perforated gallbladder: a retrospective cohort study. Asian J Surg. 2023; 46(6): 2299-303.

5. Patel G, Jain A, Kumar RB, et al. Gallbladder perforation: a prospective study of its divergent appearance and management. Euroasian J Hepatogastroenterol. 2019; 9(1): 14-9.

6. Akıncı Ö. Diagnostic value of computed tomography in gallbladder perforation. Cerrahpaşa Med J. 2023; 47(2): 197-201.

7. Abusedera MA, Khaliel M, Hassan AEMA. Surgical and non-surgical treatment of non-traumatic gallbladder perforation. Egypt J Radiol Nucl Med. 2017; 48(1): 43-9.

8. Suleiman J, Mremi A, Tarmohamed M, et al. Concealed gallbladder perforation: a rare case report. J Surg Case Rep. 2021; 2021(6): rjab245.