Rare Complication Of Acute Cholecystitis Research Articles

Gall bladder perforation: critical analysis of management at tertiary care centre

Background: Gall bladder perforation (GBP) is a rare complication of acute cholecystitis. Despite considerable advancements in diagnostic and therapeutic modalities, morbidity and mortality continues to be high, owing to delay in diagnosis and ill-defined treatment protocols. Methods: We reviewed demographic profile, diagnosis and management strategies employed in 28 patients at our centre from Jan 2018 till Jul 2020. Patients were classified based on Niemeier classification. Results: A total of 28 patients were identified but 3 excluded due to paucity of data. There were 21 patients of Niemeier type II perforation and 02 each of type I and III. Diagnosis of GBP was based on CECT in 18 patients. In patients with type II perforation, 03 underwent emergency laparoscopic cholecystectomy (LC) though one required conversion. Twelve patients were managed conservatively followed by interval cholecystectomy after mean duration of 14 weeks. Of these 08 successfully underwent LC and 03 were converted to open surgery. One patient underwent open radical cholecystectomy due to intraoperative suspicion of carcinoma. 06 patients of type II perforation underwent percutaneous drainage of collection followed by LC after mean duration of 23 weeks. Histopathology revealed chronic cholecystitis in 16 patients, acute cholecystitis in 05, carcinoma in 02 and xantho-granulomatous cholecystitis in one patient. Conclusions: CECT should be employed early for diagnosis in suspected cases and percutaneous intervention should be used in cases unresponsive to conservative measures alone. There are higher chances of success in performing LC after 14 weeks leading to better outcomes.

Spontaneous haemorrhagic cholecystitis secondary to the use of novel anticoagulants (rivaroxaban)

Haemorrhagic cholecystitis is a rare complication of acute cholecystitis. It carriesa high risk of morbidity and mortality. Risk factors for haemorrhagic cholecystitis include cholelithiasis, trauma, malignancy and the use of anticoagulants. There have only been a few reported cases of haemorrhagic cholecystitis secondary to the use of novel oral anticoagulants (NOACs). The demographic transition of an ageing population will potentially increase the utilisation of NOACs. Therefore the incidence ofhaemorrhagic cholecystitis secondary to NOACs will likely increase. Awareness and prompt diagnosis is paramount to avoid morbidity and mortality associated with haemorrhagiccholecystitis.

S372 Cystic Artery Pseudoaneurysm: A Rare Case of Upper Gastrointestinal Bleeding

Introduction: Cystic artery pseudoaneurysm (CAP) is a rare complication of acute cholecystitis and cholecystectomy. We present an unusual case of upper GI bleed due to CAP. Case Description/Methods: An elderly female presented with one month history of lethargy and unintentional weight loss. Clinical exam was unremarkable apart from pallor. Blood tests revealed severe iron deficiency anaemia and bland cholestasis. CT scan showed a common bile duct (CBD) mass and a gallbladder (GB) neck lesion with prominent regional lymph nodes, which was worrying for biliary malignancy. MRI scan showed a 3cm CBD stone with acute emphysematous cholecystitis and possible CAP at the GB neck. An urgent OGD and ERCP was done on the same day as she developed hematemesis and cholangitis. On endoscopy, there was active bleeding from possible enteric fistula at first part of duodenum (D1), this was treated with metal clips. During ERCP, haemobilia was noted on CBD cannulation. On cholangiogram, the endoclips were adjacent to distal CBD stone. A plastic stent was inserted into the CBD and she was referred to the surgeons. Cholecystectomy and CBD exploration was performed for definitive treatment. Intra-operatively, there was active bleeding into the GB from CAP. D1 was thinned out with adhesions to the GB. There was stale blood in the bile duct but no biliary-enteric fistula seen. CAP was sutured, adhesiolysis, subtotal cholecystectomy, omental patch repair of D1 and CBD stone was retrieved. Repeat OGD and ERCP with CBD stent removal done 2 months later showed healed D1 mucosa. Discussion: The clinical features of CAP include right upper quadrant pain, upper GI bleed due to haemobilia and abnormal liver enzymes. It is diagnosed on arterial phase of CT scan, angiography, MRI or during surgery. It is treated with surgery or angioembolization. This is a challenging case with delayed diagnosis of CAP as she lacks the typical presentation of CAP. A plain contrasted CT without arterial phase was done initially, which have mistaken the CAP as soft tissue lesion in GB. Endoscopic findings raises possibility of choledocho-duodenal fistula; this was excluded during surgery. The final diagnosis is acute calculous cholecystitis complicated by CAP with direct pressure on D1 leading to upper GI bleed. To our knowledge, this is the first case of CAP with such entity. In conclusion, CAP should be considered in patients with symptomatic gallstone disease and upper GI bleed in order to select appropriate imaging modality and guide therapy. Watch the video at https://tinyurl.com/ACGAbstractS372

Cystic Artery Pseudoaneurysm with Concurrent Cholecystoduodenal Fistula—Endovascular Management and Review of Literature

AbstractA rare complication of acute cholecystitis is a pseudoaneurysm of the cystic artery. We discuss a case of a 65-year-old man with synchronous cholecystoenteric fistula and cystic artery pseudoaneurysm managed by selective angioembolization of the cystic artery, followed by interval cholecystectomy.

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.

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.

Colecistitis hemorrágica, a propósito de un caso

Introducción: La colecistitis hemorrágica es una patología muy poco frecuente y de alta mortalidad. Sin embargo, puede o no estar asociada a cálculos biliares. La colecistitis hemorrágica es de difícil diagnóstico. Los cambios inflamatorios desencadenados por la hemorragia, causan ulceración de la mucosa y necrosis, acompañando a una inflamación sostenida donde interactúan citoquinas; provocando una dilatación exagerada de la vesícula biliar y finalmente su ruptura, causando hemoperitoneo e incluso la muerte.
 Objetivo: Describir un caso clínico de un paciente con colecistitis hemorrágica como complicación de colecistitis aguda.
 Material y métodos: Estudio descriptivo retrospectivo, presentación de caso clínico.
 Resultados: Se presenta el caso de un paciente sexo masculino de 39 años, que sufrió un episodio de dolor abdominal intenso acompañado de vómitos e ictericia en facies; por lo cual requirió evaluación médica con exámenes complementarios y procedimiento quirúrgico inmediato. Se realizó una colecistectomía laparoscópica urgente que reveló una vesícula biliar tensa y necrótica con múltiples litos en su interior y una mucosa aplanada, ulcerada focalmente mientras que el resto de la túnica muestra sangrado abundante.
 Conclusiones: La colecistitis hemorrágica, es una complicación importante y rara de la colecistitis aguda, muy difícil de diagnosticarla preoperatoriamente. Sin embargo, el cirujano debe conocerla y manejarla adecuadamente; puesto que, al correlacionar: la clínica, el laboratorio y los métodos de imagen, que estén a su alcance; brindará un tratamiento quirúrgico temprano y disminuirá significativamente la morbimortalidad del paciente.

Gallbladder Perforation: A Prospective Study of Its Divergent Appearance and Management.

ABSTRACTIntroductionGallstone disease is one of the most common surgical diseases. Complications associated with cholelithiasis is not uncommon, but gallbladder perforation is a rare complication of acute cholecystitis with cholelithiasis. This gallbladder perforation may present in different ways like free perforation inside peritoneal cavity causing generalized peritonitis, localized collection around gallbladder fossa after perforation and in chronic cases cholecystoenteric fistula. Here we present our experience of this condition with a review of literature for a different presentation of this condition.Materials and methodsThis study was done for 2 years, and patients who were diagnosed with gallbladder perforation either preoperatively or intraoperatively were included.ResultsThere was a total of 16 patient included in the study during this period which were either diagnosed preoperatively or intraoperatively of gallbladder perforation (GBP).ConclusionGBP, though a rare complication of cholecystitis with high morbidity and mortality, has no specific pathognomic feature and is often misdiagnosed or late diagnosed. Nowadays most cases can be managed with improved diagnostic means and therapeutic modalities (endoscopic, laparoscopic, endostaplers).How to cite this articlePatel G, Jain A, et al. Gallbladder Perforation: A Prospective Study of Its Divergent Appearance and Management. Euroasian J Hepatogastroenterol 2019;9(1):14-19.

Gall bladder perforation; occurrence, clinical presentation, diagnosis and their outcome: a retrospective study in a tertiary care hospital in South India

Background: Gall bladder perforation (GBP), is an uncommon complication of acute cholecystitis but it often remains a cause for diagnostic dilemma among surgeons while managing patients presenting with signs and symptoms of peritonitis. This study was undertaken to study the clinical profile of the patients diagnosed to have GBP which would aid in early diagnosis and surgical intervention thus improving the patient’s outcome.Methods: A retrospective study from May 2013 to April 2018 with a sample size of 12 cases were studied. All cases were diagnosed either pre-operatively (based on radiological findings) or intra-operatively. Perforations of gall bladder caused due to trauma or iatrogenic reasons were excluded from the study. Intra-operative findings, post-operative sequelae and the outcome of the patient were evaluated.Results: The mean age of the patients was 66 and females were more affected than the males. USG done preoperatively could pick up only 1 out of 12 cases. Whereas CT showed gall bladder perforation in 3 out of 4 cases for whom CT was done giving it a sensitivity of 75%. Gall bladder perforation was commonly found to be located in the fundus followed by corpus and infundibulum.Conclusions: GBP is a rare complication of acute cholecystitis. It can present with full blown peritonitis features or vague abdominal symptoms. If promptly diagnosed and treated aggressively by laparotomy and cholecystectomy, the patient’s outcomes are improved.

A rare complication of acute cholecystitis leading to perihepatic abscess: gall bladder perforation

Background: Gallbladder perforation secondary to cholecystitis are rarely seen. Gallbladder perforation is associated with intra or extra-hepatic abscesses and peritonitis and is high mortality rates. We report a case of gallbladder perforation. Case presentation: An 80 year old male patient was admitted to our hospital with abdominal pain. The aspartate aminotransferase, alanine aminotransferase and C-reactive protein values of the patient were high. The patient underwent intravenous contrast-enhanced abdominal computed tomography. Abdominal computed tomography showed a hydropic gallbladder, loculated fluid collections surrounding the liver and an increase in the gallbladder wall thickness. There was also defect in fundus of the gallbladder. The patient was operated based on clinical and radiological findings. Operative findings confirmed preoperative radiological findings. Conclusion: Gallbladder perforation is rare but in such cases early diagnosis is of vital importance. Ultrasonography and computed tomography are the imaging modalities for the diagnosis of gallbladder perforation.

Rupture of Cystic Artery Pseudoaneurysm: a Rare Complication of Acute Cholecystitis.

Pseudoaneurysm (PA) of the cystic artery is rare. Most of the reported cases are iatrogenic and develop secondary to liver biopsy, laparoscopic cholecystectomy, ERCP, and liver transplant. Other reported causes include trauma, malignancy, arteriovenous malformations, and inflammation in the hepatobiliary and pancreatic system. Cystic artery psuedoaneurysm is usually asymptomatic but may also present as vague abdominal pain, intra-abdominal mass, and hemobilia. In the event of rupture, it may present as a catastrophic intra-peritoneal bleeding with hemorrhagic shock. Doppler ultrasound and contrast-enhanced CT scan are useful tools for the diagnosis of this condition. However, selective visceral angiography is confirmatory and offers the opportunity for therapeutic embolization. We report a case which presented with upper right quadrant abdominal pain, vomiting, and hypotension. Abdominal ultrasonography revealed subhepatic hematoma and pericholecystic fluid collection along with acute calculus cholecystitis and sludge in the bile duct. Subsequent contrast-enhanced CT and CT angiography confirmed the presence of ruptured cystic artery psuedoaneurysm with subhepatic hematoma. The patient after resuscitation underwent selective visceral angiography and successful coil embolization of the cystic artery pseudoaneurysm. During the same admission, ERCP and biliary stenting were also performed followed by laparoscopic cholecystectomy. This case reports a rare entity which was successfully treated using a multimodality strategy.

Spontaneous Biloma: A Rare Complication of Acute Cholecystitis

Spontaneous Biloma: A Rare Complication of Acute Cholecystitis

An unusual cause of acute internal haemorrhage: cystic artery pseudoaneurysm secondary to acute cholecystitis

Spontaneous cystic artery haemorrhage is a rare complication of acute cholecystitis. Here we describe a case report of this unusual cause of internal haemorrhage, and discuss the pathogenesis and management strategies.

Unruptured Pseudoaneurysm of the cystic artery associated with acute calculus cholecystitis.

Cystic artery pseudoaneurysm (CAP) is a very rare complication of acute cholecystitis. We present the unruptured cystic artery pseudoaneurysm of an oedematous, thick-walled gallbladder in a 71-year old gentleman admitted with acute calculus cholecystitis. This was managed by radiological microcoil embolisation, percutaneous drainage of pericholic fluid and conservative treatment with antibiotics.

A rare complication of acute cholecystitis: transhepatic perforation associated with massive intraperitoneal hemorrhage

A 2 to 11% of the patients with acute cholecystitis that will develop gallbladder perforation and massive intraperitoneal hemorrhage as a result of perforation will rarely be seen. Massive intraperitoneal hemorrhage associated with the transhepatic perforation is very uncommon. By this article, we anticipate presenting clinical and radiological findings in a case that has acute cholecystitis with massive intraperitoneal hemorrhage associated with transhepatic perforation.

Focal Transmural Necrosis of the Gallbladder with Bleeding Resulting in a Massive Haemoperitoneum

A case of massive haemoperitoneum as a complication of focal transmural necrosis of the gallbladder with bleeding during acute cholecystitis is reported. Urgent laparotomy and cholecystectomy was performed to secure an adequate haemostasis. A review of the literature confirmed that this condition is a very rare complication of acute cholecystitis. Only 44 similar cases have been reported between 1858 and 1996. In our case, bleeding was caused by the edges of a necrotic zone in the gallbladder wall.