Acute Cholecystitis after Percutaneous Liver Biopsy in the Absence of Hemobilia

Abstract

Purpose: Percutaneous liver biopsy (PCNB) is the standard method for obtaining liver tissue in the management of acute and chronic liver disease. Known complications of PCNB include hemoperitoneum, sucapsular hematoma, hypotension, pnuemothorax and sepsis. Acute cholecystitis associated with hemobilia is very rare and is thought to be secondary to obstruction of the cystic duct by clotted blood. Herein, we describe a unique case of cholecystitis after a PCNB in the absence of hemobilia. Case Report: A 42 year old man underwent an outpatient liver biopsy for staging of chronic hepatitis C. The liver biopsy was uneventful and he was discharged home 4 hours later. The patient presented to the ER that same evening with right upper quadrant pain but was discharged after laboratory studies demonstrated normal liver tests. He returned 48 hours later with worsening right upper quadrant pain associated with nausea and emesis. He was noted to have right upper quadrant tenderness and a positive Murphy's sign. He had a leukocyte count of 23,000/mm3, hematocrit of 39%, normal coagulation profile and normal liver tests. Abdominal ultrasound revealed a distended gallbladder with diffuse wall thickening and pericholecystic fluid. There was echogenic material inside. Laparoscopic cholescystectomy was performed the following morning. The gallbladder was distended with moderate amount of blood around the liver and gallbladder. The cystic lymph node was enlarged. On histological examination the gallbladder consisted of moderate amounts of tan-brown viscous fluid and multiple diminutive tan black calculi ranging from 0.1 – 0.3 cm in greatest dimension. The postoperative course was uneventful and the patient was discharged home 2 days later. Discussion: We report an exceedingly rare complication of acute cholecystitis secondary to PCNB. The liver biopsy in our case was performed by a Trucut needle with one pass made. There was a very strong temporal relationship between the procedure and the onset of symptoms, which occurred within 7 hours after the procedure. Although the symptoms and cholecystitis could have been attributable to hemobilia, none was identified at laparoscopy or during pathological assessment after cholecystectomy. We hypothesize that the blood lying around the gallbladder (from the liver biopsy) incited gallbladder wall irritation which then led to acute cholecystitis.