Elizabeth A Verrico, DO1, Lindsay Tse, DO2, Justin Sargent, DO1, Fred Wolodiger, MD3, Steven Shikiar, MD1. 1Hackensack Meridian Health Palisades Medical Center, 2Houston Methodist Hospital, 3Englewood Hospital and Medical Center
Acute cholecystitis is one of the most common general surgery pathologies. Perforated cholecystitis is a rare potentially life threatening complication of acute cholecystitis. It is often described as acute perforation with acute peritonitis, subacute perforation with abscess and localized peritonitis, or chronic perforation with cholecystoenteric fistulation. Rare cases of spontaneous perforation have been reported but almost all cases are associated with acute inflammation.
This is a case of a 51 year old female who presented with mild non-radiating right upper quadrant and epigastric abdominal pain without associated nausea, vomiting, or fever. She denied similar symptoms in the past and her past medical history was only significant for hypertension and migraine headaches. She had no prior history of abdominal surgery. Physical exam revealed tenderness in the right upper quadrant without peritoneal signs. Labs were unremarkable except for mild leukocytosis. Ultrasound revealed a gallbladder filled with stones without pericholecystic fluid or gallbladder wall thickening. Due to persistence of symptoms the patient was taken to the operating room for laparoscopic cholecystectomy. Upon entry into the peritoneal cavity, hemoperitoneum was noted, particularly in the right paracolic gutter and perihepatic spaces. Upon further inspection and dissection, a gall bladder ulceration and perforation was noted with bleeding of the ulcerated edges and multiple stones visible. Successful laparoscopic cholecystectomy was performed with evacuation of the hemoperitoneum and collection of loose gallstones. Post-operative course was uneventful. Pathology revealed a 2.3cm jagged hemorrhagic ulceratation/perforation of the gall bladder with multiple stones causing indentations in the mucosa with moderate acute and chronic cholecystitis.
Perforated cholecystitis is uncommon. Presentation varies and can be indistinguishable from uncomplicated acute cholecystitis or can present with peritonitis, sepsis, and hemodynamic instability. This case demonstrates a very unique presentation of gall bladder perforation. The patient was minimally symptomatic without definite signs or symptoms of acute cholecystitis. There was minimal to no bile leakage from the gall bladder but there was hemoperitoneum and hemorrhage from the ulcerated edges of the perforation. Consideration of perforated cholecystitis is important on the differential diagnosis when treating patients presenting with right upper quadrant abdominal pain. There is relatively high morbidity and mortality from delay in diagnosis and high index of suspicion is required. Treatment varies depending on presentation.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95874
Program Number: P210
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster