Hemorrhagic Cholecystitis Research Articles

S1738 Hemorrhagic Cholecystitis: A Rare Cause of Brisk Upper Gastrointestinal Bleeding

Introduction: Gastrointestinal bleeding is a commonly seen problem in the hospital and timely identification of the source is important in brisk bleeds to allow for prompt interventions. Unfortunately, the cause of the bleeding can sometimes be difficult to identify and can require thinking outside the box. We present a rare case of hemorrhagic cholecystitis manifesting as hematochezia and hypotension in the setting of chronic liver disease. Case Description/Methods: A 55-year-old man with history of alcoholic cirrhosis (Meld-Na 24, Child-Pugh C) initially presented to an outside hospital with one week of nausea, vomiting, abdominal pain and watery diarrhea in the setting of alcohol withdrawal. He underwent an esophagogastroduodenoscopy (EGD) revealing a single gastric varix with red nipple without active bleeding and no esophageal varices. His liver function began to worsen and improved with supportive care. His improvement interestingly correlated with acute onset of hematochezia. A repeat EGD and colonoscopy revealed numerous blood clots in the colon without an active source of bleeding. He was transferred to our academic medical center for higher level of care. Upon arrival, he continued to have hematemesis and hematochezia. Repeat EGD/colonoscopy showed small non-bleeding gastric varices as well as massive maroon-colored clots throughout the colon and terminal ileum but no signs of active bleeding. CT angiography (CTA) revealed hyperdense material within the gallbladder lumen and extrahepatic biliary ductal systems suspicious for hemobilia and acute hemorrhagic cholecystitis. Pt underwent capsule endoscopy revealing an irregular oozing of blood in the proximal small intestine. A push enteroscopy then revealed actively oozing blood from the ampulla of Vater (Figure). Patient subsequently underwent successful cholecystostomy tube placement and cystic artery embolization with resolution of his bleeding. Discussion: Hemorrhagic cholecystitis is an infrequent complication of cholecystitis with few published case reports. Due to the rarity of hemorrhagic cholecystitis causing brisk upper gastrointestinal bleeding with hematochezia, the cause of the bleeding was overlooked despite numerous endoscopies and not found until a capsule endoscopy was performed. This case teaches us to keep our differentials broad when the cause of the gastrointestinal bleeding is unclear. Prompt recognition can lead to earlier diagnosis and intervention to improve outcomes in this patient population.Figure 1.: Enteroscopy demonstrating bleeding at the Ampulla of Vater.

Mirizzi Syndrome in the Setting of Hemorrhagic Cholecystitis.

Mirizzi Syndrome in the Setting of Hemorrhagic Cholecystitis.

EP-341 Haemorrhagic Cholecystitis with cystic artery pseudo-aneurysm

Abstract Introduction Haemorrhagic cholecystitis and cystic artery pseudo-aneurysm (CAP) are two very uncommon causes of right upper abdominal pain. However, the development of haemorrhagic cholecystitis induced by ruptured cystic artery pseudo-aneurysm and haemobilia are extremely rarely documented with few occurrences documented in the literature. Case presentation A 80year-old frail patient was admitted with RUQ pain, deranged LFTs and melaena. She had known gall stones, hypertension, chronic kidney disease and fibromyalgia. She demonstrated localized tenderness in the right abdomen and bloods showed a significant drop in haemoglobin which required blood transfusion. Abdominal ultrasound showed cholecystitis and MRCP showed CBD dilatation with no choledocholithiasis. She was found to have haemorrhagic cholecystitis and CAP along with a cholecysto-colonic fistula on triple phase liver CT. The patient underwent urgent embolization of the CAP and remained clinically stable. She was discharged home with a plan of further review before consideration for cholecystectomy. Clinical discussion Haemorrhagic cholecystitis and CAP are rare. Clinical suspicion is warranted to diagnose the case – the combination of features of cholecystitis with acute anaemia should raise the suspicion. Diagnosis is made primarily by pathognomonic findings on appropriate phase of CT and US imaging. Prompt diagnosis and management is essential in preventing mortality and/or significant morbidity. Conclusion A rare consequence of intra-biliary bleeding due to ruptured CAP leading to haemorrhagic cholecystitis is a potential differential diagnosis in patients presenting with right upper abdominal pain and haemoglobin drop. Close liaison with radiologist is warranted to organise appropriate investigation for diagnosis and successfully manage the condition.

Emergency Department Diagnosis of Postprocedural Hemorrhagic Cholecystitis Utilizing Point-of-Care Ultrasound

BackgroundHemorrhagic cholecystitis is a rare cause of abdominal pain. Most often described in the setting of blunt abdominal trauma, anticoagulation use, coagulopathy (such as cirrhosis or renal failure), and malignancy (biliary angiosarcoma), this rare condition can be difficult to identify unless high on the differential. With point-of-care ultrasound becoming more commonplace in the emergency department (ED), this tool can be successfully used to make a timely diagnosis in the correct clinical context. Case ReportA 64-year-old man with a past medical history of paroxysmal atrial fibrillation status post ablation on rivaroxaban, myelodysplastic syndrome, nonalcoholic steatohepatitis, gastroesophageal reflux disease, clonal cytopenias of undetermined significance, hypertension, and chronic pain presented to the ED with complaints of right upper quadrant pain in the setting of a recent transjugular liver biopsy. Using point-of-care ultrasound, the patient was diagnosed with hemorrhagic cholecystitis. This is an incredibly rare entity, with 87 documented cases in the literature, only two of which are in the setting of transjugular liver biopsy. The patient was ultimately managed conservatively until he had worsening symptoms, and a laparoscopic cholecystectomy was performed. The patient tolerated the procedure well and recovered. Why Should an Emergency Physician Be Aware of This?Hemorrhagic cholecystitis is a rare pathology that can be easily recognized during point-of-care ultrasound examination. This allows for rapid diagnosis and surgical consultation to provide the patient with timely definitive management.

The Clinical Significance of Hemorrhagic Cholecystitis.

Background:Hemorrhagic cholecystitis (HC) is a rare complication of acute cholecystitis. HC is difficult to diagnose pre-operatively and previous case reports suggest a strong association with anticoagulation and an increased morbidity. The purpose of the study is to determine the clinical presentation and outcomes of patients with HC in a large cohort of patients.Method:A retrospective review of HC patients diagnosed following review of the clinical and pathological database between January 1, 2000 – June 30, 2021 at two hospitals. A search of the histopathology database, patient medical records, laboratory results, and imaging was conducted.Results:Thirty-five patients were diagnosed on the histopathology report from approximately 6458 patients who had cholecystectomies. Thirty-one had emergency presentation and four patients (11.4%) had elective surgery. Twenty-one patients (60%) were female and 15 patients (40%) were male. The median age was 51 years. All patients had laparoscopic cholecystectomy, four patients were converted to open and five patients required postoperative endoscopic retrograde cholangiopancreatography. Two patients (5.7%) were on anticoagulation therapy. Twenty-three (65.7%) had ultrasound, 12 patients (34.2%) had computed tomography, three patients (8.5%) had magnetic resonance cholangiopancreatography, and one patient with a pre-operative diagnosis of HC.Conclusion:HC is a rare form of acute cholecystitis. Anticoagulation only accounts for a small fraction of these patients. Pre-operative diagnosis of HC is not often made. Patients were treated with cholecystectomies and made a full recovery with no complications. Our study seems to show HC is a histological diagnosis with no clinical consequences for the patients.

An Unusual Case of Haemobilia

Introduction: Haemobilia a rare cause of acute abdomen presents with Quincke’s triad: right upper quadrant pain, jaundice and gastrointestinal bleeding. Hemorrhagic cholecystitis is a rare cause of haemobilia. Case Presentation: A 30 year-old gentleman presented with right upper quadrant pain for 5 days, associated with fever, vomiting and jaundice. Patient was pale and icteric and right hypochondrium was tender with palpable gallbladder. His hemoglobin was 7.7 gm/dl with deranged liver function test (LFT). Abdominal ultrasonography demonstrated edematous and contracted gallbladder wall with echogenic lesion within the lumen. Computed tomography (CT) scan of abdomen revealed a mildly distended gallbladder, bilateral intrahepatic biliary radical dilatation and dilated common bile duct (CBD) with hyperdense sludge in the gallbladder and CBD. Patient developed per rectal bleeding on the fourth day of admission. Upper GI endoscopy showed blood pooling from ampulla of Vater. Abnormal blushing of gallbladder wall with abnormal enhancement at neck of gallbladder arising from cystic artery, was noted on angiography, suggestive of hemorrhagic cholecystitis. During surgery thickened gallbladder wall, engorged cystic artery and blood mixed with clot was seen in the gallbladder lumen. Cholecystectomy with choledochoscopy was performed. Choledochoscopy demonstrated normal extrahepatic biliary channel. Post-operative period was uneventful, blood hemoglobin level was static and LFT improved. Patient was discharged on fourth post-operative day. Conclusions: Haemobilia can be fatal condition hence mandates urgent diagnosis and treatment. Hemorrhagic cholecystitis is not to be forgotten as a cause of haemobilia.

Gallbladder perforation and massive intraperitoneal bleeding secondary to haemorrhagic cholecystitis

A 76-year-old man on apixaban presented with abdominal pain, vomiting, and signs of haemorrhagic shock. Imaging showed large volume haemoperitoneum with active arterial extravasation in the gallbladder fossa. The patient proceeded to emergency laparotomy, where haemorrhage was thought to arise from within a perforated gallbladder. Cholecystectomy was performed and haemostasis was achieved. Histology showed features of subacute on chronic cholecystitis, with some sections suggestive of an underlying arteritis. Haemorrhagic cholecystitis is rare, and gallbladder perforation with massive intraperitoneal haemorrhage is rarer still. This article presents a case report and literature review of this entity.

Hemorrhagic cholecystitis from isolated gallbladder injury following blunt abdominal trauma: An unusual case report.

Introduction and importanceGallbladder contusion after blunt abdominal trauma is a rare event that presents with diagnostic challenges. There is no clear evidence supporting conservative or surgical management of gallbladder contusion injuries, especially when they present in isolation. Here, we report the first case of an isolated gallbladder contusion injury after blunt abdominal trauma resulting in hemorrhagic cholecystitis that was successfully managed non-operatively.Case presentationA 22-year-old male patient presented with a 3-day history of severe right upper quadrant pain, leukocytosis, and elevated bilirubin after suffering blunt abdominal trauma from being kicked in the abdomen during a soccer game. The patient was evaluated using computed tomography (CT), ultrasound (US), and magnetic resonance cholangiopancreatography (MRCP). His imaging findings were consistent with cholecystitis without cholelithiasis. His bloodwork and imaging were initially concerning for choledocholithiasis, but were later determined to be blood products within the common bile duct (CBD). Through conservative management, which included antibiotics, bed rest, and bowel rest, he had complete resolution of symptoms and normalization of bloodwork after four days of admission and remained symptom free at 1-year.Clinical discussionThis case serves to highlight isolated gallbladder contusion as a potential outcome of blunt abdominal trauma. We re-affirm the diagnostic inconsistencies between CT and US in the work-up of cholecystitis and other biliary pathology. Furthermore, we describe the role of non-operative management in the treatment of traumatic cholecystitis, in the absence of gallstones.ConclusionGallbladder contusion and hemorrhagic cholecystitis after blunt abdominal trauma can be managed with non-operative interventions.

Hemorrhagic cholecystitis: a diagnostic challenge where the radiologist can make the difference

Hemorrhagic cholecystitis: a diagnostic challenge where the radiologist can make the difference

Isolated acute hemorrhagic cholecystitis in liver cirrhosis after blunt trauma

Isolated acute hemorrhagic cholecystitis (AHC) after blunt trauma is extremely rare. Thus, alcoholic liver cirrhosis can be a risk factor for this type of injury. The use of point-of-care ultrasound as a monitoring tool for suspicious gallbladder injuries facilitates rapid recognition and decision-making. Therefore, laparoscopic cholecystectomy was recommended for treating traumatic AHC in patients with hemodynamically stable liver cirrhosis.

Emergency laparoscopic cholecystectomy for hemorrhagic cholecystitis: A case report.

IntroductionHemorrhagic cholecystitis (HC) is a rare but specific complication of acute cholecystitis. HC progression often leads to fatal and severe outcomes.Presentation of caseWe describe the case of a 64-year-old man who was diagnosed with HC. Intraoperatively, the gallbladder surface was congested. The resected specimen had no gallstones and showed basophilic degenerate material toward the mucosal surface. In addition, vascular congestion and red cell extravasation were noted at the bottom of the layer. The patient's postoperative course was good, and he was discharged with remission 4 days following the operation.DiscussionDiagnosis and treatment during early stages are the most critical aspects of HC management and may lead to improved outcomes.We successfully performed timely laparoscopic cholecystectomy for the treatment of HC.ConclusionIn cases where HC occurs, appropriate treatment should be chosen by experiential judgment and consideration of the current literature.

S2352 An Uncommon Presentation of Hemorrhagic Cholecystitis

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.

S2353 Hemobilia and Hemorrhagic Cholecystitis Caused by Systemic Vasodilator Therapy for Pulmonary Arterial Hypertension

S2353 Hemobilia and Hemorrhagic Cholecystitis Caused by Systemic Vasodilator Therapy for Pulmonary Arterial Hypertension

Hemorrhagic Cholecystitis: A Rare Cause of Melena

Hemorrhagic cholecystitis -- a rare cause of hemobilia and melena -- is an atypical presentation of calculous cholecystitis, associated with significant morbidity and mortality. A 75-year-old woman with multiple comorbidities, who was undergoing dual antiplatelet therapy, presented with symptoms of acute cholecystitis. Two days later, she developed melena and symptoms of obstructive jaundice. Following radiological evaluation, a diagnosis of hemorrhagic cholecystitis was made. The patient was managed conservatively with IV antibiotics and blood transfusion in the initial period (clopidogrel was withheld); an interval cholecystectomy was performed six weeks later. Hemorrhagic cholecystitis is a rare complication of acute cholecystitis, and its diagnosis is challenging as it mimics various other hepatopancreaticobiliary diseases. Management options include early surgery or conservative management at the initial stage, followed by interval cholecystectomy.

Hemorrhagic cholecystitis in a patient with alcoholic liver disease

Hemorrhagic cholecystitis is a rare disease with high morbidity and mortality, especially in patients with cirrhosis. Here, we described a case of perforated hemorrhagic cholecystitis in a patient with alcoholic liver disease. A 47-year-old male with a history of alcoholic abuse was presented to the hospital with severe right upper quadrant abdominal pain. He has never been diagnosed with a specific underlying disease. In the emergency room, the initial hemoglobin level was 11 g/dL, but decreased to 8.4 g/dL after 6 hours. On physical examination, there was a palpable mass with tenderness in the right upper quadrant area. On abdomino-pelvis computed tomography, it showed highly attenuated, homogenous materials in the gallbladder, and a diffuse gallbladder wall thickening with edematous change. We performed laparoscopic cholecystectomy that revealed a gallbladder filled with large blood clots and hemoperitoneum. Although hemorrhagic cholecystitis is a rare entity of acute cholecystitis, it should be considered in high risks patients, such as trauma, malignancy, the use of anticoagulation and higher bleeding tendency in dialysis patient. Therefore, early diagnosis of this potentially fatal complication is important to facilitate urgent surgical management.

Complications of cholecystitis: a comprehensive contemporary imaging review.

Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting to the emergency department. Ultrasound, computed tomography, HIDA scans, and magnetic resonance imaging are increasingly utilized to evaluate suspected cases. The prognosis of acute cholecystitis is usually excellent with timely diagnosis and management. However, complications associated with cholecystitis pose a considerable challenge to the clinician and radiologist. Complications of acute cholecystitis may result from secondary bacterial infection or mural ischemia secondary to increased intramural pressure. The recognized subtypes of complicated cholecystitis are hemorrhagic, gangrenous, and emphysematous cholecystitis, as well as gallbladder perforation. Acute acalculous cholecystitis is a form of cholecystitis that occurs as a complication of severe illness in the absence of gallstones or without gallstone-related inflammation. Complicated cholecystitis may cause significant morbidity and mortality, and early diagnosis and recognition play a pivotal role in the management and early surgical planning. As appropriate utilization of imaging resources plays an essential role in diagnosis and management, the emergency radiologist should be aware of the spectrum of complications related to cholecystitis and the characteristic imaging features. This article aims to offer a comprehensive contemporary review of clinical and cross-sectional imaging findings of complications associated with cholecystitis. In conclusion, cross-sectional imaging is pivotal in identifying the complications related to cholecystitis. Preoperative detection of this complicated cholecystitis can help the care providers and operating surgeon to be prepared for a potentially more complicated procedure and course of recovery.

Hemorrhagic cholecystitis

Hemorrhagic cholecystitis

A haemorrhagic cholecystitis presenting as obstructive jaundice

A haemorrhagic cholecystitis presenting as obstructive jaundice

Vascular disorders of the gallbladder and bile ducts: Imaging findings.

Vascular disorders of the gallbladder and biliary tree are many and varied. In the acute setting, the clinical presentation of vascular conditions such as hemorrhagic cholecystitis and gangrenous cholecystitis are non-specific and rely on imaging for diagnosis and triaging for emergent surgery. These hemorrhagic and ischemic complications of acute cholecystitis are uncommon but potentially fatal. Hemorrhage into the gallbladder and biliary tree, from other causes, may itself result in acute cholecystitis. Knowledge of vascular anatomy of the gallbladder and biliary tree is essential for surgeons to prevent significant operative bleeding complications, particularly in laparoscopic cholecystectomy. The unique venous drainage of the gallbladder and biliary tree, with their connections to the portal venous system, lends itself to less well-recognised vascular phenomena such as gallbladder varices, portal biliopathy, and gallbladder bed perfusion abnormalities.

Hemorrhagic cholecystitis: ultrasound and CT imaging findings—a retrospective case review series

Gallbladder pathology is diverse, and imaging tests are essential tools for its diagnosis. Acute cholecystitis has multiple manifestations or complications, one of which is hemorrhagic cholecystitis (HC). In the current literature, this pathology has been described only in the spectrum of acute cholecystitis complications, case reports, or series with a maximum of 2 to 3 cases. After a retrospective review, we present 11 cases of hemorrhagic cholecystitis and discuss its various causes, clinical presentations, and findings on ultrasound (US) and computed tomography (CT), considering dual-energy CT and magnetic resonance imaging (MRI). A retrospective review of 6 years (2012-2018) of hemorrhagic cholecystitis cases diagnosed at our hospital was performed. A search engine of medical terms was used and the database of radiological cases in the emergency department of the hospital. After a careful review by two emergency and one abdominal radiologists, 11 patients were identified as hemorrhagic cholecystitis cases according to their clinical, radiological, and surgical records and confirmed with pathology reports. Both lithiasis and anticoagulation/antiplatelet therapy were the most common etiologies found (9 patients, 82%). The clinical presentation may be misleading, simulating a usual cholecystitis episode with abdominal pain, nausea, and vomiting, or manifesting with signs of bile duct obstruction, hematemesis, or anemia that may compromise the patient hemodynamically and become fatal. US is useful, but CT is the most complete test for evaluating hemorrhagic cholecystitis and was performed in all the patients. The common findings were inflammatory changes in all patients (100%), hemobilia in 10 patients (91%), hemoperitoneum in 6 patients (55%), intestinal bleeding in 3 patients (27%), and occasionally perihepatic hematomas or signs of active bleeding. Although a rare entity, hemorrhagic cholecystitis may be present, and management can be delayed if the appropriate imaging modality is not used for diagnosis.