Salmonella pancolitis with acute abdomen. CT findings and review literature.

Gall bladder is more likely to perforate in cases of obstruction leading to raised intra luminal tension. Non obstructive cholecystitis is unlikely to result in perforation. Perforation complicating acute acalculus cholecystitis is often seen in association with acute infections like pneumonia, viral influenza, and in particular with typhoid where the causative organism Salmonella typhii multiply in bile in very high titers and are further concentrated in gall bladder. Perforation in such cases is likely to be caused by intense inflammation coupled with infection with more virulent organisms and existence of a immuno compromised state leading to thrombosis of the blood vessels. This in turn causes transmural necrosis and perforation. Younger patients in an immuno compromised state also have a higher incidence of perforation. Gall bladder perforations due to typhoid fever, though known, have been rarely reported over the past two decades. Most of the reported cases of enteric gall bladder perforation date back to 1970s. Peritonitis due to gall bladder perforation is associated with high mortality as quoted by Essenhigh (39.1%). This high mortality makes timely diagnosis and management of perforated gall bladder highly crucial. Diagnostic peritoneal lavage in gall ladder perforation yields bile with or without blood. However, the presence of bile indicates biliary tract injury and is not specific for gall bladder perforation. USG is useful in 70% of cases in diagnosing gall bladder perforation and detecting the defect in gall bladder wall and hence it can be used as first line imaging modality for evaluating such a case. The features of non–traumatic gall bladder perforation on USG are free fluid and fluid collections close to the gall bladder fossa, thickened gall bladder wall – 7 mm (range 3-20 mm) and localized collection in gall bladder wall. CT scan shows free fluid and localized perihepatic and gall bladder fossa collections. The gall bladder can be accurately identified and the site of perforation is often demonstrated. Perforation of the gall bladder must be treated surgically when the diagnosis is made or suspected. The preferred procedure is emergency cholecystectomy. Cholecystostomy is an acceptable alternative especially in poor risk patients.