Spontaneous gallbladder perforation: An under-recognized complication in patients with decompensated liver cirrhosis

Abstract Background: Gallbladder perforation is a rare but life-threatening condition with high mortality. Patients with decompensated liver cirrhosis may be at increased risk; however, spontaneous or occult gallbladder perforation in this population is poorly recognized. This case series reports two cases of spontaneous gallbladder perforation in advanced cirrhosis, describing presentation, laboratory and radiologic findings, and outcomes, and compares them with available literature to highlight potential risk factors. Methods: We report the cases of two middle-aged men with advanced decompensated cirrhosis and portal hypertension, without prior biliary symptoms or gallstones on pre-event imaging, developed spontaneous gallbladder perforation. In the first case, perforation was incidentally identified during liver transplantation, and the post-operative course was uncomplicated. In the second case, the patient developed secondary bacterial peritonitis and persistent bacteremia; imaging during clinical deterioration revealed gallbladder perforation, and the patient progressed to refractory septic shock and death. We compared these cases with similar reports of spontaneous gallbladder perforation in patients with decompensated liver disease published in the literature. Results: These contrasting outcomes emphasize the diagnostic challenge of early recognition in cirrhotic patients, in whom symptoms and imaging findings may be subtle or non-specific. A proposed mechanism is portal hypertension–related gallbladder wall ischemia due to hemodynamic alterations in advanced liver disease. Conclusions: Spontaneous gallbladder perforation is an under-recognized and potentially fatal complication of decompensated cirrhosis. Clinicians should maintain a high index of suspicion in patients with unexplained abdominal symptoms or sepsis, even in the absence of gallstones.