Right Upper Quadrant Abdominal Pain Ten Years Post-laparoscopic Cholecystectomy

Abstract

Purpose: A 72-year-old woman with past history of laparoscopic cholecystectomy 10 years ago presented with a 6-month history of intermittent right upper quadrant abdominal and flank pain without association with food intake. She denied fever and weight loss. Physical examination revealed erythema and tenderness in the right lateral aspect of the upper abdomen. Labs were unremarkable. Computed tomography (CT) of the abdomen showed a complex 21 x 5.8 x 8.8 cm perihepatic fluid collection with internal septations, which fistulized through the abdominal wall and formed a 5.6 x 2 cm subcutaneous fluid collection in the right flank. HIDA scan and MRCP ruled out bile leak. Ultrasound guided drainage of the abscess drained thick, greenish fluid. The patient was empirically started on ceftriaxone and metronidazole. Bacterial and fungal cultures as well as PPD, Echinococcus, and Entamoeba serology were all negative. Cytology revealed proteinaceous material with few inflammatory cells and many degenerated structures, suspicious for, yet not definitive of, Echinococcus cyst. Patient received a 6-week course of albendazole, and PAIR procedure (puncture, aspiration, injection, and re-aspiration) was performed with no improvement in symptoms. Repeat CT scan showed persistence of the abscess. An exploratory laparotomy was performed with 500 ml of fluid drained and evacuated 28 gallstones, confirmed by pathology, from the cavity. The fluid cultures were again negative. Repeat CT scan performed a month after the surgery showed near complete resolution of the abscess. Gallbladder perforation during laparoscopy cholecystectomy can result in spillage of gallstones into the peritoneal cavity, which may lead to the development of intra-abdominal abscesses that are easily misidentified as tumors or parasitic infections on radiography due to their similar appearance. The rarity and chronicity of this problem makes the diagnosis very challenging. Treatment requires exploratory laparotomy to remove all dropped gallstones. Less invasive procedures such as percutaneous drainage are effective for resolving acute symptoms, but allow recurrence of abscess. Most patients get a short course of antibiotics based on fluid cultures that typically reveal E. coli, Klebsiella pneumoniae, and Enterococcus. Interestingly, in our patient, the cultures were negative, suggesting that the development of the abscess was secondary to foreign body reaction to the dropped gallstones. Our case illustrates the importance of considering dropped gallstones in the differential diagnosis of intra- or extraperitoneal abscesses in any patient with a history of laparoscopic cholecystectomy, regardless of the time elapsed since surgery.