An Unusual Cause of Abdominal Pain in a Cirrhotic Patient

Abstract

Question: A 57-year-old woman presented to the emergency department (ED) with fever, chills, and right upper-quadrant abdominal pain for further evaluation. She had a history of chronic hepatitis C–related liver cirrhosis and a gallbladder stone. Sclerotherapy was previously applied for gastric varices bleeding. In the ED, the blood counts were the following: white blood cells, 10,700/mm3 (normal, 4,800–10,800/mm3), hemoglobin, 13 g/dL (normal, 12–16), and platelets 34,000/mm3 (normal, 130,000–400,000/mm3). The differential count of white blood cell was neutrophils, 95%; lymphocytes, 2%; monocytes, 3%; eosinophils, 0%; and basophils, 0%. Serum biochemistry test results were as follows: alanine aminotransferase, 16 IU/L (normal, 0–40), γ-glutamyltransferase, 26 U/L (normal, 8–61), total bilirubin, 2.07 mg/dL (normal, 0.2–1.6), and C-reactive protein, 9.54 mg/dL (normal, 0–0.5). Acute cholecystitis was suspected and abdominal computed tomography (CT) was arranged (Figure A). As compared with the previous CT scan from 2 years previously (Figure B), gallstone dislocation and perihepatic fluid accumulation was disclosed. What is the possible diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. We consulted the surgeon and gallbladder rupture was suspected because of gallstone dislocation and perihepatic ascites. Open cholecystectomy was performed and a mildly edematous gallbladder displaced on the liver surface was seen (Figure C). The ligament of cystic duct was relatively laxative. A black pigmented stone was found inside the gallbladder. Retrospectively, the CT scan (Figure A) disclosed perihepatic pseudoascites, which was a fluid-filled gallbladder. Final diagnosis was liver cirrhosis with floating gallbladder. After surgery, the patient was discharged without complications and followed in our outpatient department. The gallbladder is located adjacent to the under surface of the liver, in the plane of the interlobular fissure, with the gallbladder neck maintaining a constant relationship to the porta hepatis but may be seen in any part of the abdomen.1Meilstrup J.W. Hopper K.D. Thieme G.A. Imaging of gallbladder variants.AJR Am J Roentgenol. 1991; 157: 1205-1208Crossref PubMed Scopus (53) Google Scholar The cause of anomalous position of the gallbladder can be congential or acquired.2Naganuma S. Ishida H. Konno K. et al.Sonographic findings of anomalous position of the gallbladder.Abdom Imaging. 1998; 23: 67-72Crossref PubMed Scopus (15) Google Scholar Half of the patients with anomalous gallbladder was thought to be acquired, a result of liver cirrhosis or hepatolithiasis.2Naganuma S. Ishida H. Konno K. et al.Sonographic findings of anomalous position of the gallbladder.Abdom Imaging. 1998; 23: 67-72Crossref PubMed Scopus (15) Google Scholar If the anterior segment of the right lobe is markedly atrophied, a suprahepatic gallbladder can occur.2Naganuma S. Ishida H. Konno K. et al.Sonographic findings of anomalous position of the gallbladder.Abdom Imaging. 1998; 23: 67-72Crossref PubMed Scopus (15) Google Scholar The common clinical presentations include asymptomatic (44.4%), abdominal discomfort (22.2%), epigastragia (16.7%), nausea (11.1%), and jaundice (5.5%).2Naganuma S. Ishida H. Konno K. et al.Sonographic findings of anomalous position of the gallbladder.Abdom Imaging. 1998; 23: 67-72Crossref PubMed Scopus (15) Google Scholar In previous study, the majority of the suprahepatic or retrohepatic gallbladder patients were cirrhotic, and the anterior segment of the right lobe was markedly atrophied.2Naganuma S. Ishida H. Konno K. et al.Sonographic findings of anomalous position of the gallbladder.Abdom Imaging. 1998; 23: 67-72Crossref PubMed Scopus (15) Google Scholar It can occasionally appear as perihepatic ascites.2Naganuma S. Ishida H. Konno K. et al.Sonographic findings of anomalous position of the gallbladder.Abdom Imaging. 1998; 23: 67-72Crossref PubMed Scopus (15) Google Scholar Ultrasonography and CT provide useful findings for differential diagnosis. This pseudoascites should not be confused with a true ascites to avoid a potentially lethal and unnecessary aspiration.2Naganuma S. Ishida H. Konno K. et al.Sonographic findings of anomalous position of the gallbladder.Abdom Imaging. 1998; 23: 67-72Crossref PubMed Scopus (15) Google Scholar Percutaneous transhepatic cholecyst drainage should not be performed for anatomic abnormalities related to minimal fixation of the gallbladder to the liver bed.3Nakao A. Matsuda T. Funabiki S. et al.Gallbladder torsion: case report and review of 245 cases reported in the Japanese literature.J Hepatobiliary Pancreat Surg. 1999; 6: 418-421Crossref PubMed Scopus (74) Google Scholar Preoperative diagnosis is difficult and nonvisualization of the gallbladder in the normal position with acute cholecystitis symptoms could give rise to a suspicion of anomalously positioned gallbladder.2Naganuma S. Ishida H. Konno K. et al.Sonographic findings of anomalous position of the gallbladder.Abdom Imaging. 1998; 23: 67-72Crossref PubMed Scopus (15) Google Scholar Although floating gallbladder is rare, it may result in torsion and gangrenous change, which is a surgical emergency. Delayed operative intervention may be fatal; the mortality rate is 4.9%.3Nakao A. Matsuda T. Funabiki S. et al.Gallbladder torsion: case report and review of 245 cases reported in the Japanese literature.J Hepatobiliary Pancreat Surg. 1999; 6: 418-421Crossref PubMed Scopus (74) Google Scholar