Intrahepatic type II gall bladder perforation by a gall stone in a CAPD patient

We report a case of a 30-year old female patient with end-stage kidney disease treated by continuous ambulatory peritoneal dialysis (CAPD) who was admitted to the emergency room with fever and mild abdominal pain. A type II gall bladder perforation by a solitary gall stone with development of a liver abscess was detected by abdominal ultrasound.Gall bladder perforations are rare but have to be considered in patients with abdominal pain and fever. Abdominal ultrasound is a reliable tool to establish diagnosis.A perforation of the gall bladder represents a life-threatening complication of cholecystitis, which occurred in historical study cohorts with an incidence of up to 10-15% [1-3] during acute cholecystitis. The establishment of early cholecystectomy and improvement of antibiotic therapy regimen have reduced the risk of gall bladder perforation in acute cholecystitis to 0.8-3.2% today [4-6].Gall bladder perforation was classified by Niemeier into three categories [7]. Type I perforation presents as an acute disease with perforation into the free abdominal cavity, whereas type II perforation is characterized as a subacute stage with development of a pericholecystic abscess. Type III perforation arises in chronic cholecystitis with development of bilioenteric fistulae. Especially in chronic cholecystitis diagnosis of a gall bladder perforation may be delayed, when acute symptoms including peritonism are missing [8]. In these cases abdominal imaging by ultrasound or computed tomography is a useful tool.We report on an oligosymptomatic gall bladder perforation into the liver due to cholecystolithiasis in a patient with peritoneal dialysis.A 30-year old female patient was admitted to the emergency unit with fever (40°C) for two days, mild pain in the right upper abdomen and deteriorated health condition. The patient was treated by dialysis since nine years because of a hemolytic-uremic syndrome, for the last seven years dialysis was done via continuous ambulatory perit