ACUTE PERFORATED CHOLECYSTITIS WITH HEPATIC SUBCAPSULAR INVOLVEMENT: CASE REPORT, LITERATURE REVIEW, AND MANAGEMENT OF A RARE PATHOLOGIC PROCESS

Objectives:

Introduction:
Perforation of the gallbladder is a rare, but significant complication of unrecognized or untreated acalculous cholecystitis or acute cholecystitis with cholelithiasis. Perforation is thought to occur in approximately 0.8% of acute gallbladder pathology. Various forms of perforation such as perforation with cholecystobiliary fistulas, intrahepatic perforations with abscess formation, or subcapsular fluid collections are even rarer. Only a handful of perforations with hepatic involvement have been reported in the literature. From our limited literature review, the mainstay of treatment is IR guided cholecystostomy tube and hepatic drain with an interval cholecystectomy.

Case Report:
A 75-year-old male with a history significant for coronary artery disease status post coronary artery bypass graft, atrial fibrillation status post ablation currently on apixaban, gout, and undiagnosed diverticulosis presented as a transfer from an outside facility for right upper quadrant abdominal pain and melena. Upon arrival to our facility, the patient was tachycardic in atrial fibrillation, hypotensive with systolics in the 80s, but awake and following commands. He stated he first noticed blood in his stool with concurrent right upper quadrant abdominal pain approximately 2-3 weeks prior to presentation. CT imaging from the outside facility was significant for gallbladder inflammation with free fluid in the pelvis concerning for perforation. Ultrasound demonstrated gallbladder wall thickening with hepatic subcapsular fluid collection concerning for intrahepatic gallbladder perforation. Lab work including hepatic function panel and total bilirubin was unremarkable. Surgery was consulted for further evaluation.

Given the patient’s complex cardiac history, acute cardiac instability, and anticoagulation therapy, he was a poor surgical candidate and underwent IR drain placement in the subcapsular collection and cholecystostomy tube placement. The patient was found to have a persistent rent in the fundus of the gallbladder with fistulous communication near the right hepatic lobe, and subsequently the subcapsular space. The patient was eventually discharged with both drains in place and is scheduled to follow up for evaluation and interval cholecystectomy.

Methods:

Results:

Conclusion: Complications of perforated gallbladders, with hepatic abscess, fluid collections, or intrahepatic perforations are rare. Due to the lack of classical symptoms seen with perforation, it is difficult to clinically distinguish between patients with perforated gallbladder and uncomplicated acute cholecystitis. Appropriate imaging can aid the early diagnosis of this pathology. Early diagnosis and intervention are crucial for improved morbidity and mortality in this patient population.