Abdominal Pain, Hypotension With Rectal Bleeding: A Unique Presentation of Emphysematous Cholecystitis From Squamous Cell Carcinoma of Gallbladder (GB)

Abstract

Carcinoma of GB is a rare tumor which presents significant diagnostic challenges. We present a case of an elderly woman who presented with abdominal pain and hematochezia was found to have septic shock from emphysematous cholecystitis in the setting of squamous cell carcinoma of the gallbladder. A 70 year old woman with past medical history of hypertension, anemia, CKD Stage III and DVT on warfarin presented with diffuse abdominal pain and bright red rectal bleeding. Her initial blood pressure was 74/38 mm hg with significant epigastric tenderness on exam. Rectal exam revealed hematochezia. Labs revealed hemoglobin of 9.7 g/dL. Initially believed to have lower GI bleed in the setting of supratherapeutic INR (3.1) she was transfused fresh frozen plasma and packed red blood cells. In view of significant epigastric tenderness CT scan of abdomen was done which revealed a markedly distended stone-containing GB with wall thickening, fat stranding and gas anteriorly dependent within the GB concerning for emphysematous cholecystitis. She was treated with IV antibiotics with emergent cholecystectomy. Pathology of the GB was significant for poorly-differentiated squamous cell carcinoma with positive cystic duct lymph node and acute cholecystitis with cholelithiasis. Cancer of the GB is an uncommon malignancy comprising just 0.6% of all new cancer diagnoses, and just 3.7% of all new digestive system cancer diagnoses in 20161. Histologic subtypes include adenocarcinoma, and squamous/adenosquamous carcinoma with an incidence of 90% and 1.7-12% respectively. Occurring primarily in the elderly with a 3:1 predominance in women3,4, GB carcinoma is a highly aggressive disease entity. Due to the lack of typical presenting symptoms GB cancer is usually diagnosed in advanced stages. In certain instances, patients may present with complaints of abdominal pain, nausea and vomiting and are eventually diagnosed with cholecystitis as the tumor obstructs outflow of bile. Aim of treatment is surgical resection when possible. Our case was clinically challenging as the initial presentation was consistent with massive lower GI bleeding but the CT scan of the abdomen helped us reach to the correct diagnosis and treatment. It is important for physicians to think of a broad differential diagnosis as sometimes the disease presentation is not straight forward like in our case where in the presenting complaint of rectal bleeding eventually led to a diagnosis of squamous cell cancer of GB.1241_A.tif Figure 1: Axial view of emphysematous gallbladder with foci of anteriorly dependent air.1241_B.tif Figure 2: Coronal view of markedly distended gallbladder with multiple stones, irregularly thickened wall and pericholecystic fluid.