S2220 It’s the Bloody Gallbladder! Spontaneous Gallbladder Hemorrhage Following Factor Xa Inhibition

Abstract

INTRODUCTION: Spontaneous gallbladder hemorrhage (GBH) has been a rare diagnosis associated with either trauma, malignancy or vascular abnormalities. However, GBH has recently been associated with anticoagulation. Clinical presentations vary and GBH carries significant morbidity and mortality. We present a case of a patient presenting with right upper quadrant (RUQ) pain following initiation of apixaban therapy 6 weeks prior. CASE DESCRIPTION/METHODS: A 55-year-old male presented with RUQ pain radiating to his back and right lower quadrant with subjective fevers. No history of recent trauma was provided. Past medical history was significant for hypertension, diabetes mellitus, ESRD with recent deceased donor kidney transplantation and post-operative deep venous thrombosis requiring apixaban therapy. Physical exam was notable for RUQ tenderness & negative Murphy’s sign. Initial labs were significant for a hemoglobin of 7.1 g/dL (baseline 8.4 g/dL), AST 322 U/L, ALT 644 U/L, and alkaline phosphatase of 295 U/L. RUQ ultrasound (US) demonstrated a liver measuring 15.4 cm, distended gallbladder (GB) with large volume heterogenous echogenic material but no GB wall thickening or hyperemia along with negative sonographic Murphy’s sign (Figure 1). HIDA indicated cystic duct obstruction. CT abdomen discovered increased GB size with heterogenous hyperdense material within the GB lumen (Figure 2). Patient underwent laparoscopic cholecystectomy converted to open due to poor visualization. A large and distended GB was found at open cholecystectomy, requiring ligation of a pulsatile cystic artery and cautery of multiple small bleeding collateral vessels going into the GB. 1L of blood loss was reported from small vessel bleeding, tearing of liver capsule and continued oozing from GB fossa. Pathology revealed a denuded GB with chronic cholecystitis, hemorrhage and hematoma formation (Figure 3). Following surgery, the patient has remained without RUQ pain for 8 months. DISCUSSION: Spontaneous GBH is a diagnosis which requires a high level of suspicion, especially in patients with RUQ pain, anemia and anticoagulation therapy. Presentation of GB hemorrhage may be heterogenous ranging from vague abdominal pain, overt GI bleeding and hemobilia. Prompt abdominal US and CT imaging is recommended for quick diagnosis. Treatment is with cholecystectomy in stable patients or cholecystostomy in the unstable patient. Given the increase in use of anticoagulants, clinicians should be aware of this clinical scenario in those with RUQ pain.Figure 1.: RUQ US longitudinal view showing large volume heterogenous material causing distension in the gallbladder lumen.Figure 2.: CT axial view abdomen: Gallbladder distention with heterogeneous hyperdense material within the lumen.Figure 3.: Pathology: Denuded gallbladder with chronic cholecystitis, hemorrhage and hematoma formation.