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Clin Case Rep. 2017 April; 5(4): 541–542.
Published online 2017 March 2. doi:  10.1002/ccr3.870
PMCID: PMC5378829

Gallbladder perforation: a case report in Nepal

Key Clinical Message

Gallbladder perforation has a high morbidity and mortality especially because of delayed diagnosis. Also, most of these cases are diagnosed only during surgery. Although a rare cause, it should be ruled out in cases where other causes of peritonitis cannot be established.

Keywords: Cholecystitis, gallbladder perforation, Nepal, Niemeier

A 45‐year‐old male patient presented to the emergency with vomiting for 4 days and features of peritonitis that was preceded with upper abdominal pain. He had low‐grade fever and neutrophilic leukocytosis. Plain erect chest X‐ray did not show free gas under diaphragm, and USG showed moderate free fluid in peritoneal cavity with thickened gallbladder and few stones within. CT scan was not available. What is the probable diagnosis?

  1. Duodenal perforation with peritonitis
  2. Appendicular perforation with peritonitis
  3. Gallbladder perforation with peritonitis
  4. Enteric perforation with peritonitis

Answer: 3. Gallbladder perforation with peritonitis.

Here, we report a Niemeier type I perforation of gallbladder. This patient underwent emergency exploratory laparotomy with cholecystectomy. Finding was bilious fluid with few purulent flakes in peritoneal cavity (Fig. (Fig.1),1), and the bowel was normal. Gallbladder was thickened and edematous with a single perforation in fundus with necrotic edges and few stones within. Postoperative recovery was uneventful. The biopsy report showed acute cholecystitis with necrotic gallbladder and single perforation in fundus.

Figure 1
Intra‐operative finding: Gallbladder perforation at fundus.

It is difficult to differentiate GB perforation from cholecystitis in initial period as both have similar symptoms. This delay in diagnosis is the main cause for morbidity and mortality 1. Niemeier classified gallbladder perforation in 1934 2 and is recommended that cases be classified accordingly to maintain consistency in reporting.

Conflict of Interest

None declared.


TS: participated in study conception and design; involved in acquisition of data; analyzed and interpreted the data; drafted the manuscript; and performed critical revision.


1. Menakuru S. R., Kaman L., Behera A., Singh R., and Katariya R. N.. 2004. Current management of gall bladder perforations. ANZ J. Surg. 74:843–846. [PubMed]
2. Niemeier O. W. 1934. Acute free perforation of the gall‐bladder. Ann. Surg. 99:922–924. [PubMed]

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