Scrotal Gallstones: A Not-So-Silent Gallbladder Perforation With Streptococcus sanguinis Peritonitis: 2482

INTRODUCTION: Gallbladder perforation (GBP) is rare and potentially life-threatening. Diagnosis is difficult, and high index of suspicion should be maintained for a patient presenting with cholecystitis. Prompt operative consideration for GBP is recommended. Gallstone disease is more common in patients with cirrhosis, though risk of morbidity and mortality with surgery is often high. We present a case of GBP complicated by peritonitis to illustrate the complexity of managing this condition in a patient with comorbid cirrhosis. CASE DESCRIPTION/METHODS: A 58 year-old man with alcohol-related cirrhosis (Child Pugh C) presented with fatigue, abdominal pain 2 weeks after a large volume paracentesis (LVP), LLQ approach with US. He was afebrile with a distended abdomen, jaundice, and lower quadrant tenderness. Ascitic fluid analysis showed 27 k/μL WBC with 90% neutrophils, initially concerning for peritonitis secondary to bowel perforation from the recent LVP. CT imaging was consistent with gallstones in the pelvic ascites fluid, and a large left hydrocele with stones in the scrotal sac (Figures 1–3). Diagnosis was presumed peritonitis secondary to GBP, though ultrasound and HIDA scan were negative for a gallbladder wall defect or active bile leak. Peritoneal fluid cultures grew Streptococcus sanguinis , and the patient improved with IV antibiotics. Repeat LVP and fluid analysis showed reduced WBC count. Cholecystectomy and peritoneal washout were deferred due to surgical risksin the setting of decompensated cirrhosis. Unfortunately, he developed mixed septic/hemorrhagic shock from a duodenal ulcer bleed and expired shortly thereafter. DISCUSSION: This case exemplifies the complexity in diagnosing and managing GBP in a patient with decompensated cirrhosis. Were it not for his high peritoneal fluid WBC and recent LVP prior to admission, it would be reasonable to suspect spontaneous bacterial peritonitis, CT imaging would be deferred and his GBP unrecognized. Therefore, maintaining high suspicion for GBP in a cirrhotic patient with severe peritonitis or concern for cholecystitis is recommended to avoid complications of GBP. This case also highlights the difficulty in treating GBP, or any symptomatic gallstone disease, in a decompensated cirrhotic where surgery is high risk. This patient's initial stability and decompensated cirrhosis led to deferral of operative consideration, leaving his peritoneal stones as a nidus for infection. His GI bleed was felt to be unrelated, but his septic shock expedited his decompensation.