Septic Shock from Cholecystitis in an Intrahepatic Gallbladder

Abstract

Introduction: Intrahepatic gallbladders, a rare anatomical variant, usually have impaired functionality and do not empty completely. This stasis leads to the formation of gallstones which in turn leads to an increased risk of developing associated complications with increased morbidity and mortality. We illustrate this point with a case of a male with a history of partial cholecystectomy who presented with sepsis from cholecystitis within an intrahepatic gallbladder. Case Report: A 31-year-old male presented with complaints of right upper quadrant abdominal pain, nausea and vomiting. His past medical history included cholelithiasis with elective open partial cholecystectomy a few months prior for biliary cholic. His postoperative course had been complicated by stump leakage requiring an ERCP with stent placement. On this admission, the patient presented with hypotension and tachycardia, elevated WBC count of 12.6 K/mL, total bilirubin of 1.4, and direct bilirubin 0.56. Blood cultures were positive for gram-negative bacilli. CT scan was significant for a fluid collection in the gallbladder fossa (Figure 1). MRCP revealed an intrahepatic gallbladder with dark signal representing possible calculi (Figure 2). The patient was admitted to SICU on IV antibiotics and vasopressors. The patient had 15cc of purulence drained by interventional radiology. GI was then consulted for an ERCP. The prior stent was removed, sphincterotomy performed, a cholangiogram did not reveal any bile leaks or filling defects in the common bile duct, and a new stent was placed. The patient's vital signs improved and he no longer required vasopressors within 24 hours after the ERCP. Discussion: Intrahepatic gallbladders are predisposed to develop cholelithiasis, which presents a significant cause of morbidity. A delay in diagnosis leads to inappropriate management and increases in morbidity and mortality. In our case, the patient likely required earlier stent placement because the entirety of the gallbladder was not removed during his initial surgery. The remaining portion of the gallbladder remained at risk of developing further cholelithiasis due to its anatomical position if the original gallstone was not removed during the initial cholecystectomy. Intrahepatic gallbladders should be identified early as they have a higher propensity for developing gallstones, which can lead to other complications such as cholecystitis, cholangitis, perforation, abscess formation and even death.Figure 1Figure 2