Operative Management of Liver Abscess and Intra-hepatic Migration of Gallstones due to Perforated Cholecystitis

Abstract

We report a rare case and an atypical presentation of acute cholangitis and cholecystitis complicated by intrahepatic gallbladder perforation, forming a multilocular liver abscess with stones embedded within the abscess cavity in a forty-six-year-old gentleman. He presented with painless jaundice, pale stools, and dark urine. His initial investigations revealed leukocytosis, obstructive liver function tests and computerised tomography of the abdomen revealed a perforated gallbladder with segment 5/6 liver abscess containing multiple dependent calculi in segment 6 and distal CBD calculi. Endoscopic-Retrograde-Cholangiopancreatography was performed, with endoscopic sphincterotomy and retrieval of common bile duct stones. This was followed by ultrasound-guided percutaneous cholecystectomy. He was then treated with la[aroscopic cholecystectomy, deroofment and debridement of abscess and retrieval of intrahepatic stones. In the setting of hepatic abscess, percutaneous drainage and antibiotic treatment for abscess before an interval cholecystectomy, however the retained calculi within the abscess cavity in this case continue to be a nidus for infection. With decompression of the abscess by drainage and regeneration of scar tissue, the difficulty of retrieving the stones requires resection of the involved liver segments. The early timing and conduct of the operation allowed the use of a minimally invasive parenchymal-sparing approach to address the intrahepatic stones along with the cholecystectomy. While perforated gallbladder with cholecystohepatic fistula and abscess is a rare condition on its own; we believe this to be the first time an abscess from a perforated gallbladder has been complicated by migration of gallstones beyond the adjacent pericholecystic liver tissues and into non-continuous segments.