Retroperitoneal actinomycosis due to dropped gallstones

Pelvi-abdominal as a complication of long-term use of intrauterine device (IUD). The important role of imaging in diagnosis and follow-up

ACTINOMYCOSIS is a rare chronic granulomatous disease caused by anaerobic filamentous gram-positive bacteria, the most common of which is Actinomyces israelii. Actinomycetes are commensal inhabitants of the oral cavity and gastrointestinal tract, but they may become pathogenic through invasion of breached or necrotic tissue. Pelviabdominal ACTINOMYCOSIS is uncommon and can mimic a variety of disease processes, including abdominal mass mimicking malignancy, acute abdomen, asthenia, and weight loss. We describe a 38-year-old woman who presented with acute abdominal pain and tenderness, as well as constitutional manifestations and elevated inflammatory markers. On initial computerized tomography (CT) and MRI, a large fluid collection underlining the anterior abdominal wall at the false pelvic cavity, as well as parietal peritoneal enhancement and smudging of the mesenteric fat and a bulky fibroid uterus with an implanted IUD, were identified. The ultrasound guided aspiration and anaerobic culture revealed positive growth for Actinomyces bacteria. An exploratory laparoscopy revealed extensive adhesions between the abdominal wall and the small intestine, as well as hyperemic and thickened peritoneum, and peritoneal biopsy confirmed ACTINOMYCOSIS. After the diagnosis was established, the IUD was removed and the patient was given Ceftriaxone 2 gm once daily for 6 weeks before switching to oral doxycycline 100 mg twice daily for another 3 months. A significant regression of the suprapubic fluid collection, and peritoneal-mesenteric changes were confirmed on follow-up. The case is discussed, and the relevant literature reviewed and analyzed.

Dropped Gallstone Presenting as Recurrent Abdominal Wall Abscess

Dropped gallstones are a known complication of laparoscopic cholecystectomy. Rarely, dropped stones may be embedded within the potential intraperitoneal spaces or abdominal wall, mimicking metastatic implants, tuberculosis, peritoneal loose body, actinomyces, and primary tumors, which when coupled with the fact that most bile stones are radiolucent, leads to diagnostic challenges. Here, we report a case of abdominal wall abscess due to a dropped stone that presented over 15 years after laparoscopic cholecystectomy. An 86-year-old male with laparoscopic cholecystectomy for management of acute cholecystitis complicated by post-cholecystectomy choledocholithiasis over 15 years back presented to the emergency department with intermittent, asymmetric abdominal “bulging” and a reported 16-pound weight loss of 3 months duration. He remained hemodynamically stable and physical examination demonstrated approximately 9 cm × 7 cm, nontender and slightly fluctuant mass appreciable on the right lateral abdominal wall extending to the right flank. Laboratory revealed leukocytosis and elevated lactic acid. Abdominal ultrasound and abdominal computed tomography demonstrated a 10.6 × 7 × 16 cm cystic mass with echogenic debris adjacent to the anterior segment of the right hepatic lobe. The patient presented multiple times with re-accumulation. A drain was subsequently placed and antibiotic therapy initiated with subsequent resolution. Follow-up magnetic resonance imaging revealed a punctate calcification within the abscess pocket. Retained stones should be considered in the differentials of patients presenting with abdominal discomfort and abdominal “masses.” The clinical suspicion must remain high secondary to the potential temporally prolonged presentation, indolent nature of inflammation, and unusual sites of physical manifestations.

Actinomycosis presenting as an anterior abdominal mass after laparoscopic cholecystectomy

Abdominal actinomycosis is a rare disease caused by different anaerobic Actinomyces species. We report the case of a 55-year-old woman who presented with a painless, slow growing, left upper abdominal mass that developed after a laparoscopic cholecystectomy. A CT scan and MRI of the abdomen revealed a desmoid tumour of the left rectus abdominis muscle.Surgical excision was performed with an uneventful postoperative course. The histological analysis of the specimen was inconsistent with a desmoid tumour and revealed an infection of Actinomyces israelii in the anterior abdominal wall that was confirmed with a microbiology culture. The surgical treatment was followed by a course of penicillin antibiotic therapy for 6 months. This treatment resulted in full recovery with no further complications. Although it is rare, the patient's history of laparoscopic cholecystectomy was identified as the likely source of infection.

Consequences of Lost Gallstones During Laparoscopic Cholecystectomy: A Review Article

BACKGROUND

Laparoscopic cholecystectomy (LC) has become a popular and widespread procedure for the treatment of gallstone disease. There is still an increasing concern about specific complications of LC due to gallbladder perforation and spillage of bile and stones. Although unretrieved intraperitoneal gallstones rarely become symptomatic, their infective complications may cause serious morbidities even after a long interval from LC.

METHODS

We performed a review of the literature on the diagnosis, prevention, consequences, and management of lost gallstones. All studies with a focus on lost gallstones or perforated gallbladder were analyzed to evaluate the postoperative complications.

RESULTS

Between 1991 and 2015, >250 cases of postoperative complications of spilled gallstones were reviewed in the surgical literature. The most common complications are intraperitoneal abscesses and fistulas. Confusing clinical pictures due to gallstones spreading in different locations makes diagnosis challenging. Even asymptomatic dropped gallstones may masquerade intraperitoneal neoplastic lesions.

CONCLUSIONS

Every effort should be made to prevent gallbladder perforation; otherwise, they should be retrieved immediately during laparoscopy. In cases with multiple large spilled stones or infected bile, conversion to open surgery can be considered. Documentation in operative notes and awareness of patients about lost gallstones are mandatory to early recognition and treatment of any complications.

Cytopathology of Hepatobiliary-Related Actinomycosis

BACKGROUND

The clinical diagnosis of hepatobiliary-related actinomycosis can be challenging owing to its rarity and variable presentation. Moreover, actinomycotic pseudotumors may mimic malignancy and result in unnecessary surgical resection. Herein, we present the clinical and cytopathological features of 3 cases with hepatobiliary-related actinomycosis.

CASES

The first patient was a 73-year-old man who presented with an exophytic liver lesion. The second patient was a 78-year-old woman who presented with a biliary stricture. The third patient was an 88-year-old woman with a right flank mass extending to the liver. The aspirate smears in these 3 cases demonstrated 'cotton ball' clusters of filamentous microorganisms and abscesses. The cell blocks of 2 of the patients showed sulfur granules with peripheral filamentous microorganisms positive with a Gram stain but negative with an acid fast stain, consistent with Actinomyces species. All patients were elderly and shared a past surgical history of laparoscopic cholecystectomy.

CONCLUSION

These cases demonstrate the complementary role of cytology in the diagnosis of hepatobiliary actinomycosis. A cytologic diagnosis of actinomycosis is minimally invasive and quick. It can prompt proper culture medium selection and avoid unnecessary or extensive surgery. Based on our experience, laparoscopic cholecystectomy may be a precipitating factor for the subsequent development of hepatobiliary-related actinomycosis.

Abdominal wall actinomycosis simulating a malignant neoplasm: Case report and review of the literature

Abdominal wall actinomycosis is a rare disease frequently associated with the presence of an intra uterine device. We report on a case of a 47-year-old woman who had used an intrauterine device for many years and had removed it about a month prior to the identification of an abdominal wall abscess caused by Actinomyces israelii. The abscess mimicked a malignancy and the patient underwent a demolitive surgical treatment. The diagnosis was obtained only after histopathological examination. Postoperatively, the patient developed an infection of the wound which was treated with daily medication. The combination of long-term high dose antibiotic therapy with surgery led to successful treatment.

Subphrenic abscess secondary to Actinomycosis meyeri and Klebsiella ozaenae following laparoscopic cholecystectomy

A case is reported of a subphrenic abscess 12 months post-laparoscopic cholecystectomy in a 72-year-old male with identification of Actinomyces meyeri and the oropharyngeal commensal Klebsiella ozaenae. The first organism is exceptionally rare following laparoscopic cholecystectomy and is presumed to be a result of inadvertent gallstone spillage. The second organism has not previously been reported in a subphrenic abscess. The etiopathogenesis and management of this condition are presented.

Abdominal actinomycosis: a rare complication after laparoscopic gastric bypass

A 33-year-old, morbidity obese woman underwent a laparoscopic Roux-en-Y gastric bypass in November 2004. She presented 18 months later with a history of recurrent pain in the upper region of the abdomen and severe vomiting. Radiologic and endoscopic evaluations revealed wall thickening in the transverse colon and a solid tumor near the liver. Therefore, a sonography-guided biopsy of the tumor was performed. Cytopathological examination revealed actinomycosis. Thus, therapy with penicillin was started, after which the parameters associated with the infection decreased. The symptoms persisted, however, and the decision was made to operate on the patient to resect the abdominal masses. Nearly 90% of the masses could be removed. Histological analysis showed a fibro-productive inflammation with an actinomycotic etiology. Antibiotic therapy with penicillin was continued for 6 months. Actinomycosis must be considered in the differential diagnosis of patients with abdominal mass, wall thickening of the intestine, and other such symptoms, including abdominal pain following bariatric surgery, even many years after the intervention.

Abdominal Abscesses Due to Actinomycosis after Laparoscopic Cholecystectomy: Case Reports and Review

We describe 2 patients who presented to a health care facility with abdominal abscesses years after undergoing laparoscopic cholecystectomy that was complicated by gallstone spillage. In both patients, sample cultures yielded Actinomyces species and enteric organisms. In 1 patient, crystallographic analysis of abscess debris confirmed the presence of gallstones. Actinomyces species is a rare cause of abdominal abscesses that should be considered in this patient population.

Lost gallstones in laparoscopic cholecystectomy: all possible complications

BACKGROUND

Laparoscopic cholecystectomy (LC) has been the gold standard for symptomatic gallstones for 15 years. During that time, several studies and case reports have been published which outline the possible complications of lost gallstones. The aim of this review is to categorize these complications and to evaluate the frequency and management of lost gallstones.

DATA SOURCES

A Medline search from 1987 to 2005 was performed. A total of 111 case reports and studies were found, and all reported complications were listed alphabetically. Eight studies with more than 500 LCs that reported lost gallstones and perforated gallbladder were analyzed for frequency and management of lost gallstones.

CONCLUSION

Lost gallstones have a low incidence of causing complications but have a large variety of possible postoperative problems. Every effort should be made to remove spilled gallstones to prevent further complications, but conversion is not mandatory.

Abdominal actinomycosis

Abdominal actinomycosis has been recognised for over 150 years yet remains largely unknown to most clinicians. It's varied presentations are usually considered to represent malignancy rather than an infective process - and was once described as 'the most misdiagnosed disease'. Actinomyces are gram positive bacilli of the Actinomycetales genus, and A. israelii is responsible for the majority of human disease. They are normal commensal inhabitants of the human bronchial and gastrointestinal tracts and seem to only cause pathological infection after preceding mucosal breakdown. Patients who have undergone appendicectomy, have had a missed perforated appendicitis or women with a history of intrauterine contraceptive device use are at an increased risk. Florid abscess formation with fistulation, abundant granulation and dense surrounding fibrosis are common. Diagnosis prior to, or even during, surgery is rare and the findings are usually mistaken for acute inflammatory pathologies or malignancy. The treatment of choice is prolonged antibiotic therapy, usually with penicillin to which the organisms remain exquisitely sensitive, although delayed recurrence is possible. This review outlines the historical background of actinomyceal infection and considers the epidemiology, pathophysiology and clinical features of abdominal actinomycosis.

Retroperitoneoscopy to Extract Dropped Gallstones After Laparoscopic Cholecystectomy

Complications resulting from gallstones left in the peritoneal cavity are most often reported after laparoscopic treatment of cholelitiasis. Gallstones are frequently dropped in the posterior subhepatic space, which can lead to the development of abscesses that usually require laparotomy for extraction of the stones. We present a novel technique for treating collections associated with dropped gallstones, using retroperitoneoscopy with two 10-mm ports after ultrasound localization of the abscess. We carried out this procedure in two patients and successfully extracted the gallstones without postoperative complications or recurrences. We consider this approach to be technically feasible, safe, and effective. It avoids the usual inefficacy of simple percutaneous drainage of these collections and the complications associated with the drainage of intra-abdominal abscesses by laparotomy.