Perforated and complicated cholecystitis: a narrative review of diagnosis, management, and differentiation from gallbladder cancer.

Abstract

Background: Perforated cholecystitis is a severe complication of gallbladder inflammation that is associated with substantial morbidity and mortality. Diagnosis is often challenging because clinical and radiographic findings overlap with those of uncomplicated cholecystitis and, in some patients, with gallbladder malignancy. This review summarizes the current evidence regarding the diagnosis, imaging, management strategies, outcomes, and differentiation of perforated cholecystitis from gallbladder cancer.

Methods: A comprehensive literature review was conducted using PubMed and Embase from inception to May 2026. Eligible studies included full-text articles, case reports, and original research describing perforated cholecystitis with an emphasis on diagnosis, treatment, outcomes, and gallbladder cancer mimicry.

Results: Gallbladder perforation results from progressive inflammation, ischemia, and mural necrosis, most commonly involving the fundus of the gallbladder. The Niemeier classification categorizes perforations into acute free perforation (type I), localized perforation with abscess formation (type II), and chronic perforation with fistula formation (type III). Advanced age, male sex, diabetes, cardiovascular disease, delayed presentation, and nonoperative management are identified as important risk factors. Computed tomography (CT) is the most sensitive diagnostic modality, demonstrating wall defects, pericholecystic collections, abscesses, bilomas, and extraluminal gallstones. Management includes cholecystectomy, percutaneous cholecystostomy, and interval surgery for selected patients at high risk. Evidence regarding the optimal surgical timing remains inconsistent. Chronic perforation and xanthogranulomatous inflammation may closely mimic gallbladder carcinoma on imaging and intraoperative assessment.

Conclusion: Perforated cholecystitis is a diagnostically challenging and potentially life-threatening condition. CT imaging is central to the diagnosis, whereas management should be individualized according to the patient's status and perforation type. Greater recognition of the features distinguishing perforation from gallbladder malignancy may facilitate earlier diagnosis and improve outcomes. When malignancy is a significant consideration, and the patient's condition permits, consider early referral to a hepatopancreatobiliary surgeon or a multidisciplinary hepatobiliary team to guide further diagnostic evaluation, including tissue acquisition when appropriate, and definitive surgical planning.