[A case of spontaneous hemorrhagic cholecystitis without gallstone]

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

BACKGROUND

Hemorrhagic 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 REPORT

A 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.

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.

Surgical case report-acalculous hemorrhagic cholecystitis

Haemorrhagic cholecystitis is a seldom seen cause of right upper quadrant pain that can result in gallbladder rupture, massive intraperitoneal haemorrhage and death if untreated. Haemorrhagic cholecystitis is usually seen in the presence of cholelithiasis, malignancy, trauma and coagulopathies. Here, we present the unusual case of an elderly man presenting with acalculous haemorrhagic cholecystitis, who was successfully treated with laparoscopic cholecystectomy. We review the radiological and laparoscopic findings of haemorrhagic acalculous cholecystitis. This case highlights the importance of prudent use of radiological imaging to differentiate haemorrhagic cholecystitis from alternate pathology and early surgical intervention to avoid massive intraperitoneal haemorrhage and the high mortality with which it is associated.

Haemobilia Secondary to Spontaneous Cystic Artery-Gallbladder Fistula: A Unique Gastrointestinal Anomaly

Spontaneous cystic artery-gallbladder fistula is an extremely rare condition described in the medical literature. We have found two articles in the literature describing fistula formation between the cystic artery and gall bladder. In this report, we present a unique case of a cystic artery-gall bladder fistula that resulted in massive gastrointestinal bleeding through cystic artery erosion and was adequately managed with coil embolization.

Emergency cholecystectomy and hepatic arterial repair in a patient presenting with haemobilia and massive gastrointestinal haemorrhage due to a spontaneous cystic artery gallbladder fistula masquerading as a pseudoaneurysm

BACKGROUND

Haemobilia usually occurs secondary to accidental or iatrogenic hepatobiliary trauma. It can occasionally present with cataclysmal upper gastrointestinal haemorrhage posing as a life threatening emergency. Haemobilia can very rarely be a complication of acute cholecystitis. Here we report a case of haemobilia manifesting as massive gastrointestinal haemorrhage in a patient without any prior history of biliary surgery or intervention and present a brief review of literature.

CASE PRESENTATION

A 22 year old male admitted with history suggestive of acute cholecystitis subsequently developed waxing waning jaundice and recurrent episodes of upper gastrointestinal bleed. Endoscopy showed an ulcer in the first part of duodenum with a clot, no active bleed was visible. Angiography was suggestive of a ruptured pseudoaneurysm in the vicinity of the right hepatic artery probably originating from the cystic artery. Coil embolization was tried but the coil dislodged into the right branch of hepatic artery distal to the site of pseudoaneurysm. Review of angiographic video in light of operative findings demonstrated a fistulous communication between cystic artery and gallbladder as the cause, a simultaneous cholecystoduodenal fistula was also noted. Retrograde cholecystectomy, closure of cholecystoduodenal fistula and right hepatic arteriotomy with retrieval of the endo-coil and hepatic arterial repair was performed.

CONCLUSION

Fistula between the cystic artery and gallbladder has been commonly reported to occur after laparoscopic cholecystectomy. Spontaneous fistulous communication, i.e. in the absence of any prior trauma or intervention, between cystic artery and gallbladder is rare with very few reports in literature. Aetiopathogenesis of the disease, in the context of current literature is reviewed. The diagnostic dilemma posed by the confounding finding of an ulcer in the duodenum, the iconic video angiographic depiction as also the therapeutic challenge of a failed embolization with consequent microcoil migration and primary hepatic arterial repair in the emergency situation is discussed.

Hemorrhagic cholecystitis: report of a case

Hemorrhagic cholecystitis is an uncommon cause of abdominal pain that can be fatal. We report a case of hemorrhagic cholecystitis in a 75-year-old male taking an anticoagulant. The patient was brought to the hospital with uncontrolled right upper quadrant abdominal pain. On computed tomography, mild gallbladder wall thickening and high density with gallstones in the gallbladder suggested acute calculous cholecystitis or hemorrhagic cholecystitis. An urgent laparoscopic cholecystectomy was performed that revealed a gallbladder filled with large blood clots and two black stones. Patients who develop hemorrhagic complications were often receiving anticoagulation therapy or had pathologic coagulopathy. An early diagnosis of this potentially fatal condition is important to facilitate urgent surgical treatment.