Post-Traumatic Gallbladder Injury in Children: Case Rapport

Post-traumatic injuries of the gall bladder are rare. We report through a clinical description of its physio-pathological and evolutionary aspects. A 14-year-old boy was received 48 hours after a stabbing attack. After initial haemorrhage, the patient presented clinical improvement; then a sudden deterioration with vague symptoms and disturbance of the hepatic balance. The abdominal CT scan revealed a perivesicular hematoma with a focus on hepatic contusion. Laparoscopy showed a penetrating sore of the liver, but the exploration was limited by an important inflammation of the digestive tract. The diagnosis of gall bladder perforation was made during the operation. We performed a cholecystectomy by laparotomy. Postoperative evolution was simple, removal of the slides at D + 4 and discharged at D + 7 postoperative after improvement. At the 6th month, he presented an acute intestinal obstruction on bridles, managed at emergency by open surgery. After one year of follow up, the patient has no symptoms. We note that the vague clinical presentation and the limit of imaging examinations made the early diagnosis of a vesicular perforation a real challenge for the clinician. Cholecystectomy remains the optimal treatment.

valuable tool for the rapid identification of gallbladder injury [4]. Although other therapeutic approaches are described, cholecystectomy is the optimal treatment [5].
Our purpose is to present through a clinical description of a post-traumatic gallbladder injury, its physio-pathological and evolutionary aspects.

Case Report
14-year-old boy: a victim of abdominal trauma following a stabbing attack. Hospitalized initially at a peripheral hospital where he received primary care. It is received 2 days after trauma with normal vitals parameters. Clinically, the examination was marked by a right base-thoracic wound of 3 cm, a distended sensitive abdomen (epigastrium the right hypochondrium and the flanks). An abdominal ultrasound found a hepatic contusion (left lobe) associated with haemoperitoneum, the gallbladder seems normal but it contains echogenic sediment, probably hemobilia ( Figure 1). The angio scan showed an abundant haemoperitoneum with a peri vesicular hematoma, and hepatic contusion (segment IV).
He benefited from a biological assessment (Table 1), prophylaxis antibiotic, blood transfusion; clinical biology and radiology monitoring. He was discharged on the 5th day after clinical stabilization. It is readmitted at D + 8 of the trauma for haematic fluid with lumps of pus through the para-gastric wound. Biological assessment (Table 1)   After one year of follow up, the patient has no symptoms.

Discussion
Post-traumatic vesicular lesions are rare, accounting for 1.9% of all abdominal trauma. This rarity is probably related to the protection of the organ by its visceral relations and the rib cage [1] [2] [4]. Often in association with the involvement of other organs including the liver in 83% to 91% and 54% for duodenal and spleen disorders [5].
The clinical presentation and symptoms of gallbladder perforation are monopolized by the associated lesions. Isolated, perforation of the gall bladder is often of delayed presentation with vague symptoms [6]. In many cases, the first symptoms are mild, consisting of abdominal discomfort and diarrhea. Biliary peritonitis may be present initially. A remission period variable is described before sudden deterioration [6]. Oumar Ndour et al. [7] reported the case of a After a period of hemorrhage our patient presented a good clinical remission before being readmitted 72 hours in clinical and biological deterioration.
Biological analyses are not contributory to either positive diagnosis or differential diagnosis. Sanguine numerous formula will be late in hematoma-related blood spoliation, but useful in monitoring hemorrhage [8].
Disturbances in the hepatic function do not automatically have a direct hepatic lesion significance, but may be indirect in cases of extra-hepatic biliary disease but with hepatic impact [8].
In the traumatic context, observable disturbances have no diagnostic or prognostic value. If we can expect a very disturbed liver assessment in case of serious injury, they do not make the prognosis either. One should not rely on the normality of a liver test in a low suspicion of traumatic hepatic injury to eliminate this lesion; also valid for a lesion of the bile ducts [8].
Our patient was referred for a post-traumatic hemorrhage, clinically stable on examination which justifies our choice to perform a first-line angio-scanner.
However, it only identified perivascular hematoma. The diagnosis of perforation was per operative. And according to the classification of Losanoff and Kjossev [9], our patient is classified as type 2.
Ultrasound is the cornerstone of the initial evaluation of the poly traumatized for the abdominal and thoracic part. The bile ducts are poorly visualizable and one cannot eliminate a biliary lesion by focus assessment ultrasound for trauma, nor even correctly suspect it [10]. Open Journal of Pediatrics must then look for the involvement of other organs [12]. Cholecystectomy is the optimal treatment [5].
The cholecystorraphy of penetrating lesions has been described, but this procedure presents risks such as a loss of repair and subsequent biliary leakage. In addition, even resorbable sutures placed in the vesicular wall may form a nest for subsequent formation of stones [12].
Cholecystectomy by laparoscopy has been described as the treatment of isolated perforation of the gallbladder due to abdominal injury [13]. However, the laparoscopy approach has certain limitations and is generally not recommended in the case of gallbladder injury, in which other concomitant lesions should be excluded. Although the laparoscope can give a good superficial view of the peritoneal cavity and excellent diaphragmatic view, inspection of the duodenum, pancreas and left hepatitis is not enough in the hands of most general surgeons without experience advanced laparoscopy [13].

Conclusion
Post-traumatic lesions of the gall bladder are rare, the vague clinical presentation and limited imaging tests in some forms make early diagnosis a real challenge for the clinician. Cholecystectomy remains the optimal treatment despite recent proposals for conservative treatment.

Ethical Aspects
Parental consent has been obtained for the use of patient's data for possible publication. We have strictly respected confidentiality and anonymity.