Perforated Hemorrhagic Cholecystitis: 1222

An 88 year-old male with significant CAD, prior CABG, atrial fibrillation and CHF, presented to our hospital with worsening right upper quadrant (RUQ) abdominal pain of a 24-hour duration. He has been on aspirin, clopidogrel and apixaban, amongst many other meds. Two weeks prior to presentation, the pt had coronary artery stent placement. Following this procedure, he developed RUQ abdominal pain with radiation to the rest of his abdomen. He had poor appetite but no nausea or emesis. CT A/P showed nonspecific gallbladder (GB) wall thickening and GB distention, moderate bilateral pleural effusions, and pelvic ascites. RUQ US showed mild GB wall thickening and sludge but no gallstones. There was no GB dilatation. The pt was thought to have cholecystitis and was started on IV ampicillin/sulbactam. He also underwent thoracentesis which showed a transudative effusion and thought to be from fluid overload state. Pt improved and was discharged home. His RUQ abdominal pain worsened 24 hours prior to presentation and became constant. It was deep, aching and without radiation. He denied fevers or chills. On exam, he was afebrile, BP 125/67mmHg and HR 92bpm. Abdomen was diffusely tender to palpation, particularly in RUQ with positive Murphy sign. No rebound tenderness. Labs showed WBC 11.3, Hgb 12.7, platelets 368, Na 130, K 3.9, Cl 94, Cr 0.9, TBili 1.0, ALT 68, AST 88, alk phos 429, lactate 1.5, lipase 44. Blood cultures were negative. CT A/P showed hemorrhagic cholecystitis with perforation of GB wall at the fundus (Images), reactive bowel wall thickening of the cecum and hepatic flexure, hemorrhagic ascites and a moderate right sided pleural effusion. Given his cardiac comorbidities, recent coronary artery stenting, current triple antiplatelet/anticoagulation therapy, surgery was delayed. He was treated with IV piperacillin/tazobactam, holding antiplatelet/anticoagulation therapy, and blood transfusion as needed. He underwent laparoscopic subtotal cholecystectomy and drainage of perihepatic hematoma 7 days later and was discharged 4 days postoperatively in stable condition on his antiplatelet meds. Perforated hemorrhagic GB is a very rare complication of acute cholecystitis and is associated with high mortality. Management entails emergent surgery. In this case, our pt likely developed hemorrhagic cholecystitis due to antiplt/anticoagulant use. Because of hemodynamic stability and pt comorbidities, conservative management was preferred initially.Figure 1Figure 2Figure 3