Unexpected peritonitis: spontaneous gallbladder perforation without prior cholecystitis in an elderly patient- A case report"

Introduction and Importance: Gallbladder perforation is a rare but serious complication, usually following acute cholecystitis. Spontaneous perforation without prior biliary symptoms is extremely uncommon and often presents as acute peritonitis, especially in the elderly and/or immunocompromised patients. Early diagnosis and prompt surgical intervention are essential to reduce morbidity and mortality. Case Presentation: A 76-year-old male with no prior history of gallbladder disease presented with a 3-day history of right upper quadrant pain and signs of generalized peritonitis. Imaging revealed a perforation in the gallbladder fundus with pericholecystic fluid and intraluminal stones. Emergency laparotomy confirmed a 5 mm fundal perforation with 500 ml of bile-stained peritoneal fluid. Cholecystectomy and peritoneal lavage were performed. The patient recovered uneventfully. Clinical Discussion: Spontaneous gallbladder perforation is rare, especially without prior cholecystitis. It most commonly occurs at the fundus due to its limited blood supply, making it susceptible to ischemia. While cholecystitis is more frequent in females, perforation is more common in elderly males. Clinical signs may be nonspecific, and perforation is often diagnosed only via imaging or intraoperatively. Contrast-enhanced computed tomography is the most sensitive imaging modality, identifying mural defects, pericholecystic fluid, and fat stranding. Laparoscopic or open cholecystectomy with peritoneal lavage remains the mainstay of treatment. Conclusion: Spontaneous gallbladder perforation should be considered in elderly patients with an acute abdomen, even without a history of gallbladder disease. Timely imaging and surgical management are vital for favorable outcomes. Early recognition, appropriate classification, and individualized treatment planning can significantly reduce complications and improve long-term prognosis. Keywords: gallbladder, perforation, acute abdomen, cholecystectomy, Niemeier classification, cholecystitis, case report.