1. PATIENT PRESENTATION
An 83‐year‐old man (6 months status post‐laparoscopic cholecystectomy) presented to the emergency departmentcomplaining of acutely worsening abdominal and chest pain that had been present for the past several months. Of note, his immediate post‐operative course was complicated by a subphrenic fluid collection, right‐sided pleural effusion, and pneumoperitoneum requiring exploratory laparotomy with drain and chest tube placement. Examination revealed a temperature of 99.5°F, heart rate of 104 bpm, blood pressure of 116/69 mm Hg, and respiratory rate of 26 breaths/min. Pertinent laboratory results included a WBC count of 35.3 K/μL with neutrophilic predominance (92.1%) and a hemoglobin of 9.4 g/dL. The emergency physician performed a bedside point‐of‐care ultrasound (Figures 1, 2, 3, 4; Video 1) and later confirmed the diagnosis with computed tomography (CT) of the chest and abdomen (Figures 5 and 6).
FIGURE 1.
Ultrasound of the right upper quadrant demonstrating an anechoic, cystic appearing, fluid collection (arrow) within the liver parenchyma
FIGURE 2.
Color flow Doppler is applied demonstrating a bidirectional flow pattern (arrow) consistent with the “yin‐yang” sign of a pseudoaneurysm
FIGURE 3.
Longitudinal view of the right upper quadrant at the costophrenic angle demonstrating perihepatic fluid collections (asterisks). Superior to the diaphragm there is loss of the typical mirror image artifact of the liver, which is replaced by an area of mixed echogenicity (long arrow) (see Video 1) suggestive of a complex and septated pleural effusion
FIGURE 4.
Longitudinal view of the right upper quadrant demonstrating loss of the continuity of the right hemidiaphragm (arrows) (see Video 1) and perihepatic fluid collection (asterix)
FIGURE 5.
A CT of the chest, abdomen, and pelvis with intravenous contrast demonstrating a 5.5‐cm pseudoaneurysm (outlined by arrowheads) in the gallbladder fossa
FIGURE 6.
CT of the chest with intravenous contrast demonstrating a loculated right pleural effusion (asterisks) that extends through the diaphragm with fistulization to an abscess along the bare area of the liver (arrow)
2. DIAGNOSIS
2.1. Pseudoaneurysm of the hepatic artery with associated diaphragmatic disruption and empyema
Pseudoaneurysm formation of the cystic or hepatic arteries is a rare but well‐described complication of laparoscopic cholecystectomy. 1 Predisposing factors include inadvertent mechanical injury to the arteries during surgery, excessive or inappropriate use of thermal cauterization, and leakage of bile due to inadvertent injury to the biliary tree. 2 Pseudoaneurysms will appear as a cystic fluid collection on grey scale ultrasound; however, interrogation with color flow Doppler will reveal the characteristic “yin‐yang” sign that is created from the in‐and‐out turbulent blood flow pattern. 3 Emergent CT angiography with trans‐arterial embolization remains the gold standard for imaging and treatment of visceral artery pseudoaneurysms. 2
In our case, bedside ultrasound not only allowed for rapid diagnosis of the pseudoaneurysm, but also allowed for identification of the associated perihepatic abscess, diaphragmatic disruption, and communicating right pleural effusion with empyema. These are also rare complications of laparoscopic cholecystectomy that have often been associated with spilled and retained gallstones. 4
Supporting information
Video 1
Seymour ZR, Nolting, L Boyer B. Elderly man with abdominal and chest pain. JACEP Open. 2020;1:666–668. 10.1002/emp2.12120
REFERENCES
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Associated Data
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Supplementary Materials
Video 1