Iatrogenic gallbladder perforation

Case contribution: Dr Radhiana Hassan


  • A 76 years old man
  • Under medical team for investigation of incidental findings of lung mass
  • Referred from medical to surgical team for acute abdomen
  • Sudden onset of severe abdominal pain immediately after US-guided biopsy of right renal pelvic mass
  • First attempt with 16G needle obtained good tissue
  • Second attempt aspirated greenish bile material
  • Clinically abdomen not distended but guarded, tenderness at puncture site at right subcostal axillary line region
  • HB: 14, TWBC: 20, Plt 589
Abdominal radiograph shows no significant finding
CT scan abdomen in axial plane post contrast soft tissue window
CT scan pre and post procedure of gallbladder

CT scan findings:

  • The gallbladder is well distended, located near the right anterior abdominal wall (yellow arrows) which is adjacent to the possible puncture site (as evident by subcutaneous air).
  • The gallbladder wall is thickened and enhanced with associated pericholecystic fluid. These changes are not seen in the previous study.
  • there is no apparent irregularity of the gallbladder wall or focal area of wall discontinuation observed.
  • There is also minimal free fluid seen (mean HU 11) at perihepatic and sub hepatic which tracking into the right paracolic gutter and accumulating within the pelvis.

Intra-operative findings:

  • Exploratory laparotomy done
  • Upon entering the peritoneum bile coloured peritoneal fluid seen
  • Small bowel mildly dilated
  • Noted small perforation at the right lateral gallbladder, size of perforation about 1mm
  • Oozing of bile from the site of perforation

Diagnosis: Iatrogenic gallbladder perforation.


  • Gallbladder perforation is an uncommon complication of percutaneous biopsy
  • Conservative management for a short time is appropriate but early sign of peritoneal irritation demand surgical intervention
  • There is no specific set of findings which are of diagnostic of gallbladder injury.
  • Ultrasound may reveal heterogeneous hyperechoic blood adjacent to the gallbladder, as well as pericholecystic fluid.
  • CT is more accurate for identifying blood or discontinuity of the gallbladder wall
  • In the setting of bile peritonitis, preoperative imaging should not delay return to the OR for evaluation due to risk of sepsis and shock.
Author: radhianahassan