Type II gall bladder perforation with abdominal wall abscess in a cirrhotic patient: case report and review of the literature

Gallbladder empyema: An atypical manifestation of acute cholecystitis

INTRODUCTION AND IMPORTANCE

Acute cholecystitis is responsible for 44 % of emergency admissions to the emergency services with multiple complications such as empyema a necesitatis (EN). EN has a close relation with cholecystitis when the perforation of the gallbladder (GB) can lead to the formation of a biliary fistula. Patients can be asymptomatic, with late consultations, thus being a diagnostic challenge. Different techniques are described for cholecystitis and secondary abscess, therefore, the choice of the appropriate procedure should be the best one to reduce the high associated morbidity.

CASE PRESENTATION

We present a case of an 89-year-old patient, admitted for a sensation of a mass in the right hypochondrium with abdominal pain. He was taken to the operating room, finding a vesicular plastron with piocholecyst and perforation into the abdominal wall with abscess and fasciitis. Subtotal cholecystectomy was performed laparoscopically and an open approach in the abdominal wall, drainage of the abscess and debridement, leaving a negative pressure system.

CLINICAL DISCUSSION

EN affects elder patients with high rates of morbidity, also GB empyema, which is related with its perforation and posterior fistulization, its external spontaneous perforation is much less frequent. Fistulas originated from the biliary tract are well described in the literature, with low incidence. They are related with improved diagnostic investigations and earlier implemented treatment by antibiotics and surgery.

CONCLUSION

Biliary EN represents a very unusual complication of acute cholecystitis, its atypical presentation represents a diagnostic challenge, with very few cases documented and high mortality rates. Its management represents a challenge for the general surgeon, finding different approaches and surgical behaviors to take.

Cholecysto-hepatic fistula in type III gallbladder perforation: A rare etiology of liver abscess; case report

INTRODUCTION AND IMPORTANCE

Gallbladder perforation (GBP) with cholecystohepatic fistula is an extremely rare complication of acute and/or chronic gallbladder diseases. Niemeier classified GBP into three types each characterized by specific signs and symptoms. Radiological investigations such as abdominal ultrasonography (USG) and computed tomography (CT) are crucial to evaluate and diagnosing GBP, while fistulae are usually identified intraoperatively.

CASE PRESENTATION

A 77-year-old female patient, with a background medical history of multiple comorbidities, presented to our hospital with a one-week history of abdominal pain. Laboratory investigations showed abnormal values. The abdominal CT scan revealed a mildly enlarged liver, distended gallbladder, and liver abscess. Then, ultrasound-guided aspiration was done, and the clinical picture was consistent with calcular cholecystitis complicated with liver abscess. So, laparoscopic cholecystectomy was decided and the intraoperatively detected fistula was excised. The resected perforated gallbladder was sent for histopathological studies. The postoperative period was uneventful.

CLINICAL DISCUSSION

GBP is an unusual entity that is categorized into three types. It is considered a gallbladder complication and surgical emergency. The clinical features of GBP are non-specific and radiological tools aid in diagnosis demonstration. In the presented case of type III GBP, cholecystohepatic fistula was detected and excised intraoperatively.

CONCLUSION

Due to the rare entity of type III GBP in association with liver abscess, we report the case of a 77-year-old female with right lower quadrant pain, found to be caused by type III GBP with cholecystohepatic fistula and liver abscess.

Pyogenic Liver Abscess Complicating Acute Cholecystitis: Different Management Options

Acute cholecystitis, which is usually associated with gallstones is one of the most common surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation and abscess formation. Perforation of the gallbladder is a relatively uncommon complication of acute cholecystitis (0.8–3.2% in recent reviews). The intrahepatic perforation causing a liver abscess is an extremely rare condition, anecdotally reported in the scientific literature, even in the rare types of subacute or acute perforation. Liver abscess caused by gallbladder perforation can be a life-threatening complication with a reported mortality of 5.6%. The treatment of synchronous pyogenic liver abscess and acute cholecystitis may be challenging. We reported three cases of liver abscess due to acute cholecystitis in which different therapeutical approaches were employed. The first case was treated with antibiotics and interval laparoscopic cholecystectomy; the second case was treated with emergency cholecystectomy; and the third case with percutaneous aspiration of the abscess only. The appropriate therapeutical method in these cases depends on the patient’s clinical condition, the on-site expertise that is available in the hospital, and the experience of the surgeon.

Pyogenic Liver Abscess Complicating Acute Cholecystitis: Different Management Options

Acute cholecystitis, which is usually associated with gallstones is one of the most common surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation and abscess formation. Perforation of the gallbladder is a relatively uncommon complication of acute cholecystitis (0.8-3.2% in recent reviews). The intrahepatic perforation causing a liver abscess is an extremely rare condition, anecdotally reported in the scientific literature, even in the rare types of subacute or acute perforation. Liver abscess caused by gallbladder perforation can be a life-threatening complication with a reported mortality of 5.6%. The treatment of synchronous pyogenic liver abscess and acute cholecystitis may be challenging. We reported three cases of liver abscess due to acute cholecystitis in which different therapeutical approaches were employed. The first case was treated with antibiotics and interval laparoscopic cholecystectomy; the second case was treated with emergency cholecystectomy; and the third case with percutaneous aspiration of the abscess only. The appropriate therapeutical method in these cases depends on the patient's clinical condition, the on-site expertise that is available in the hospital, and the experience of the surgeon.

Localized gallbladder perforation: a systematic review of treatment and prognosis

BACKGROUND

The optimal management of localized gallbladder perforation (Neimeier type II) has yet to be defined. The aim of this systematic review was to identify factors associated with improved patient outcomes.

METHODS

Systematic review of studies that described the management of Neimeier type II perforation, reported complications of the first intervention, necessity of added interventions, resolution of the pathology, and days of hospital stay were included. The search strategy was conducted in EMBASE, Mayo Journals, MEDLINE, SCOPUS, and Web of Science (December 2020) RESULTS: A total of 122 patients (53% male) from case reports, series, and cohorts were included for analysis. In total 56 (46%) and 44 (36%)patients were treated with open and laparoscopic cholecystectomy respectively. Overall risk of bias was moderate. The need for another intervention was higher in the laparoscopic group (5 vs 17, p=<0.001) as well as prevalence of complications (4 vs 16, p=<0.001), but lower for days of hospital stay (median days 5. vs 15, p = 0.008) against open cholecystectomy. Preoperative percutaneous catheter drainage did not influence outcome.

CONCLUSION

Open cholecystectomy has a lower need for further surgical procedures and postoperative complications, but a longer hospital stay. These outcomes did not vary with preoperative percutaneous drainage. The effect of timing of cholecystectomy did not influence the outcomes.

Diagnosing Gallbladder Perforation With Contrast-Enhanced Ultrasound: A Case Report

Gallbladder perforation is a rare and severe complication of acute cholecystitis. Sonography is typically the first modality of choice for assessing gallbladder pathology due to its high sensitivity, portability, real-time imaging capability, and nonionizing technique. Gray-scale and color Doppler sonographic imaging may be equivocal for diagnosing perforation. In the presented case, gallbladder wall perforation was definitively diagnosed utilizing contrast-enhanced ultrasound, allowing for prompt treatment and a successful patient outcome.

Gallbladder perforation without cholecystitis in a patient awaiting liver transplantation: a peculiar case report of anaemia in cirrhosis

BACKGROUND

Acute anaemia in decompensated liver cirrhosis is commonly caused due to gastrointestinal bleeding; however, sometimes, detecting the site of blood loss is challenging. A patient on waitlist for orthotopic liver transplantation because of decompensated liver cirrhosis was admitted with acute anaemia and recurrence of ascites. Their abdomen CT showed migration of gallbladder stones in the pelvis while paracentesis documented hemoperitoneum. A diagnosis of gallbladder perforation was performed.

CONCLUSION

Challenging choice of a "wait and see" strategy with conservative therapy, avoiding high-risk cholecystectomy, resulted in a successful liver transplant.

Gallbladder perforation: a single center experience of 32 cases

Backgrounds/Aims

Gallbladder perforation is a rare but potentially fatal disease. We herein present our clinical experience in diagnosis and management of 32 cases of gallbladder perforation.

Methods

This retrospective study was conducted with inclusion of all cases of gallbladder perforation that presented to our hospital from January 2012 to November 2014. Cases of traumatic gallbladder perforation and patients younger than 12 years of age were excluded from this study.

Results

This study included 32 patients (13 males and 19 females). The mean age of patients was 55.9 years. Gallbladder perforation was most common in the 5th and 6th decade of life. The mean age of patients with type I, II, and III gallbladder perforation was 57.0 years, 57.6 years, and 49.8 years, respectively. The most common site of perforation was the fundus, followed by the body and Hartmann's pouch (24 : 5 : 2). Most of the type I gallbladder perforations were diagnosed intraoperatively, type II gallbladder perforations were diagnosed by enhanced abdominal computed tomography, and type III gallbladder perforations were diagnosed during laparoscopic cholecystectomy converted to open cholecystectomy for cholelithiasis. Mortality was highest in patients with type I gallbladder perforation. The mean hospital stay was 10.1 days, 6.4 days, and 9.2 days in patients with type I, II, and III gallbladder perforation, respectively. The histopathologic analysis in 28 patients who were operated on showed acute cholecystitis in 19 cases, acute-on-chronic cholecystitis in 4 cases, chronic cholecystitis in 4 cases, and mucinous adenocarcinoma of the gallbladder in a single case.

Conclusions

Gallbladder perforation represents a special diagnostic and surgical challenge. Appropriate classification and management are essential.

Acute gallbladder perforation with gallstones spillage in a cirrhotic patient

Gallbladder perforation is a rare complication of cholecystitis and cholelithiasis. The high morbidity and mortality rates associated with this condition are due to delays in diagnosis and treatment since signs and symptoms of perforation do not differ significantly from those of uncomplicated cholecystitis. We report on a patient who was affected by Child-Pugh A alcoholic liver cirrhosis and who developed an acute gallbladder perforation with spillage of stones into the peritoneal cavity and give a review of the current literature.