S2352 An Uncommon Presentation of Hemorrhagic Cholecystitis

Abstract

Introduction: Hemorrhagic Cholecystitis (HC) is a rare subtype of acute cholecystitis often seen in malignancy, trauma and anticoagulation use, presenting with abdominal pain and melena. Given the rarity of HC many cases are preliminarily misdiagnosed as infectious or acalculous cholecystitis based on symptomatology and imaging. This case presents with symptoms and imaging atypical for HC and discusses interventions that can be used to aide in diagnosis. Case Description/Methods: A 46 year-old man with a history of right peroneal vein thrombosis on warfarin, GERD, and alcohol abuse presented after outpatient labs showed a hemoglobin of 4.4. The patient had been experiencing fatigue, dyspnea, palpitations, and constipation with brown stool for several days. Physical exam was significant for pale mucosa and sinus tachycardia. Bloodwork showed: normocytic normochromic anemia of 4.2, total bilirubin of 1.5, negative guaiac stool and normal: reticulocyte index, LDH, and haptoglobin. Urinalysis showed urobilinogen and bilirubin and CT abdomen and pelvis without contrast was normal. To evaluate for a source of bleeding, the patient underwent CT Angiogram abdomen and pelvis that was normal. The patient underwent endoscopy and colonoscopy. A single angioectasia was seen in the gastric antrum and a patchy area of friable mucosa without active bleeding was found in the duodenal bulb and first part of the duodenum. Active bleeding from the major papilla was seen concerning for hemobillia or hemosuccus pancreaticus. Interventional radiology performed urgent angiography; however, no active source of bleeding, vascular shunting, or vascular malformation was found. The patient continued to require blood transfusions and underwent ERCP with successful hemostasis achieved by metal biliary stent placement. The patient returned to the hospital one week later, complaining of severe epigastric and right upper quadrant pain. He underwent laparoscopic cholecystectomy and was found to have hemorrhagic cholecystitis thought to be secondary to chronic anticoagulation use. Discussion: HC should not only be suspected in cases of severe abdominal pain or melena as has been documented in prior case reports. Anticoagulated patients are at an increased risk of bleeding especially from hollow organs like the esophagus, stomach and intestine. When traditional workup for source of bleeding is inconclusive, rare sources of bleeding such as HC should be suspected, with hemostasis achieved by cholecystectomy as seen in this case.Figure 1.: Endoscopy Images of Major Duodenal Papilla Bleeding.