Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 57

Fatal abdominal hemorrhage associated with gallbladder perforation due to large gallstones Luis R. Soto, MD, Harold R. Levine, MD, Scott A. Celinski, MD, and Joseph M. Guileyardo, MD Gallbladder perforation is a relatively uncommon complication of acute cholecystitis and may occur with or without gallstones. Prophylactic cholecystectomy has been recommended for patients with very large stones (>3 cm) due to an increased risk of gallbladder cancer. We present the case of a 68-year-old woman who died of hemorrhagic shock following gallbladder perforation due to very large gallstones. This case provides additional support for consideration of prophylactic cholecystectomy in patients with very large gallstones. allbladder perforation (GP) is one of the most severe complications of acute cholecystitis and is associated with a mortality of up to 70% (1). It occurs in up to 10% of patients with acute cholecystitis (2), but GP in the absence of acute cholecystitis is rare. Nontraumatic perforation results from ischemia and gangrene of the gallbladder wall and occurs most commonly in the fundus in cases of acute cholecystitis (with or without stones). Such perforations are usually contained within the subhepatic space by the omentum, duodenum, liver, or colon, and a localized abscess may form. Less commonly, the gallbladder perforates into an adjacent viscus, resulting in an enteric fistula and possible “gallstone ileus.” Rarely, the gallbladder perforates freely into the peritoneal cavity, leading to generalized peritonitis (3). Hemorrhage associated with GP is even less common, but has been reported with erosion into an adjacent artery (4). Although the incidence of GP is similar in patients with stone-related versus acalculous cholecystitis (5), the risk of GP due to very large stones in the absence of acute cholecystitis is not known. Very large gallstones have been associated with an increased risk of gallbladder cancer, and we present the following case which suggests that prevention of perforation may represent another reason for consideration of prophylactic cholecystectomy in patients with very large stones. hours later it was 14.3 K/uL with 80% segmented neutrophils and 12% band forms. Her condition rapidly declined, and she required intubation and red cell transfusions. Her admission aspartate aminotransferase was 7621 IU/L; alanine aminotransferase, 3475 IU/L; direct bilirubin, 1.2 mg/dL; total bilirubin, 2.9 mg/dL; and lactic acid, 5.8 mmol/L. Computed tomography (CT) revealed a large calcified multilayered stone within a distended gallbladder in conjunction with a large complex fluid collection around the gallbladder with extension into the liver and right paracolic gutter (Figure 1). Radiologic interpretation included possible liver mass versus abscess with GP. On the day of admission, a cholecystostomy tube was placed, and the hepatic artery was embolized with Gelfoam. Subsequently, the patient’s hemoglobin stabilized, but she developed hepatic failure with progressive jaundice and coagulopathy, followed by irreversible multisystem organ failure, and died. CASE STUDY A 68-year-old woman was admitted to Baylor University Medical Center at Dallas with right upper-quadrant abdominal pain. Her admission hemoglobin fell from 11.3 to 6.1 g/dL over several hours. Her initial white blood cell count was 17.4 K/uL with 93% segmented neutrophils (machine count), and From the Departments of Pathology (Soto, Guileyardo), Radiology (Levine), and Surgery (Celinski), Baylor University Medical Center at Dallas. Corresponding author: Joseph M. Guileyardo, MD, Department of Pathology, Baylor University Medical Center at Dallas, 3500 Gaston Avenue, Dallas, TX 75246 (e-mail: [email protected]). G Proc (Bayl Univ Med Cent) 2014;27(2):131–132 Figure 1. Coronal reformatted CT image demonstrates lamellated gallstone (red arrow) and inflammatory changes in the gallbladder fossa with “biloma” versus hemorrhage in the right hepatic lobe (blue circle). 131