Neonatal perforated gallbladder is a rare and implausible surgical emergency. Pneumoperitonium and neonatal intestinal obstruction are the main clinical presentations. Many cases of neonatal perforated gallbladder had no clear pathology. Most proper treatment is cholecystectomy during formal exploration. Gallbladder perforation due to cholecystitis is usually seen in the elderly population but is uncommon among the pediatric population. Mortality rate can be as high as 26 % hence early diagnosis is vital. Management is mostly surgical as seen in the index case.

Our case is a 15 days old infants after falling from hand of parents more less 1 meter from earth admit with crying, abdominal sensivity and Us shows liquids and pneumoperitonium, in laparotomy we find rupture of gall bladder and do cholecyctectomy for her, and discharge her healthy. 

Although perforated gallbladder is a rare entity and in most of cases does not cause pneumoperitonium, but perforated gallbladder should be taken in account of all cases of pneumoperitonium.

Spontaneous bile duct perforation in infants has been reported in the literature; however, gallbladder perforation in infants is extremely rare [2,3]. In the vast majority of cases, the underlying etiology still seems to be unknown, vascular and metabolic compromise were accused on its occurrence [3]. It has insidious presentations in the form of neonatal intestinal obstruction manifestations including billous vomiting, constipation, abdominal distention, abdominal tenderness and pneumoperitonium, making preoperative diagnosis challenging [4]. Perforated gallbladder is also uncommon in adults. It occurs in 2 % to 10 % of adult patients with acute cholecystitis, it could be diagnosed through computerized tomography, and on the other hand in neonates the diagnosis is elusive due to multiplicity of differential diagnosis [5]. With this data we report this case that shows it is a complication of infants. 

Our case is a 15 days old infants after falling from hand of parents more less 1 meter from earth one hours before and admit with crying, abdominal sensivity , nausea and vomiting . We start lab data and Us perform for her that shows liquids and pneumoperitonium,in abdomen. Laparotomy planed for her (figure1) we check liver,spleen,stomach and bowels and finally we find rupture of gall bladder(figure2) and do cholecyctectomy (Figure2) for her, After surgery we observe her and after2 days she starts water and then milk eating and discharge her healthy after3 days.

Rupture of the bladder is extremely rare in the newborns. Neonatal gallbladder perforation is rare, just 1.5 neonates every 1,000,000 live births [6,7]. The fundus is the least vascularized area supplied by blood, so it is the most susceptible area in the gallbladder to perforation [8]. Niemeier classified perforation in gallbladder into three categories in 1934: type I, acute perforation in the free peritoneal cavity which agreed with reported case; type II, subacute perforation with abscess formation; and type III, chronic perforation with fistula formation between the gallbladder and other organs [9,10]. Open cholecystectomy is the treatment of choice in this condition where some surgeons preferred a tube cholecystostomy [11,12]. Surgical exploration and cholecystectomy was done in this case with no intraoperative complications [13,14]. Gallbladder perforation due to cholecystitis is usually seen in the elderly population but is uncommon among the pediatric population. Mortality rate can be as high as 26 % hence early diagnosis is vital. Management is mostly surgical as seen in the index case [15]. Traumatic gallbladder perforations are exceeding rare and consist of only 1.9 to 2 % of all abdominal traumas [16,17]. The diagnosis is made through the clinical presentation, with patients presenting with localized or diffuse abdominal pain owing to biliary peritonitis and often diagnosed intra-operatively as seen in our case and most cases of GBP published [18]. Imaging modalities include USS and abdominal CT scans which are more sensitive as confirmed in the index case. More recently, contrast-enhanced ultrasound (CEUS) has been developed with a diagnostic accuracy for detecting solid organ injuries comparable to that of CT-scans, and has the capability of giving a more detailed description of traumatic cases [16]. 

Other modalities include Magnetic Resonance Cholangiopancreatography (MRCP) and drip-infusion cholangiography (DIC-CT) depending on the availability. Most cases are managed according to the cause, mostly through a surgical approach than conservative as a means of clearing the biliary peritonitis as well as cholecystectomy as seen in our case. Moving forward in medicine, the use of artificial intelligence (AI) will aid clinicians to detect pathologies more accurately and hence come up with an accurate diagnosis, therefore, avoiding delays in management. Currently, the use of robotic surgery is rising to perform surgeries like cholecystectomy and microsurgery. This benefits both surgeons and patients, however, challenges include projecting an overlay on markerless deformable organs and tissue deformation therefore sensors and algorithms need to be advanced and updated regularly [19]. Patients diagnosed with acalculous cholecystitis can be managed conservatively with analgesics and antibiotics and close monitoring of clinical symptoms and signs [20].

Neonatal perforated gallbladder is a rare and implausible surgical emergency. Pneumoperitonium and neonatal intestinal obstruction are the main clinical presentations. Many cases of neonatal perforated gallbladder had no clear pathology. Most proper treatment is cholecystectomy during formal exploration [1]. Gallbladder perforation although rare, but a life-threatening clinical condition with high mortality and should always be suspected in patients with acute abdomen, early diagnosis via imaging modalities and early management prompted to reduce ongoing morbidity and enhance recovery [15].

Highlights:

• The proportion of occurrence of gallbladder perforation is very rare
• No specific pathology is cause of perforation of gallbladder
• Pneumoperitonium is one of most important signs of gallbladder perforation.
• Gallbladder perforation is classified into three types according the site of perforation.
• Surgical excision of gallbladder is most proper surgical option in perforated gallbladder.

Ethical Approval and Consent to participate:

The content of this manuscript are in accordance with the declaration of Helsinki for Ethics. No committee approval was required. Oral and written consent to participate was granted by her parents.

 “Written informed consent was obtained from the patient's legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.”

It is available.

The author declares that they have no competing financial interests and nothing to disclose.

There is no funding.

Ahmad Reza Shahraki is the surgeon of patient and writes this paper.

The author declares that they have no competing financial interests and nothing to disclose.

Neonatal perforated gallbladder is a rare and implausible surgical emergency. Pneumoperitonium and neonatal intestinal obstruction are the main clinical presentations. Many cases of neonatal perforated gallbladder had no clear pathology. Most proper treatment is cholecystectomy during formal exploration. Gallbladder perforation although rare, but a life-threatening clinical condition with high mortality and should always be suspected in patients with acute abdomen, early diagnosis via imaging modalities and early management prompted to reduce ongoing morbidity and enhance recovery.