Atraumatic spontaneous hemorrhagic cholecystitis

Abstract

Hemorrhagic cholecystitis is a rare subtype of acute cholecystitis. It is considered a medical emergency, with a morbidity rate of 32% to 58% and a mortality rate of 15% to 20%. It presents with an acute onset of intense abdominal or back pain that can be mistaken for other conditions such as thoracic aortic dissection. Diagnosis hinges on a high index of suspicion and confirmatory studies, such as computed tomography scan or ultrasound. Specific risk factors identified in the literature include a history of trauma and anticoagulant use. We present an atypical case of spontaneous hemorrhagic cholecystitis with no antecedent risk factors.

Hemorrhagic cholecystitis is a rare subtype of acute cholecystitis with a reported incidence of 3.5%.¹ Its presenting symptoms are easily confused with other etiologies, as they are nonspecific and can include abdominal pain, back pain, positive Murphy’s sign, nausea, and fever.¹ Risk factors include a history of nonsteroidal antiinflammatory or anticoagulant use. Imaging through ultrasound, computed tomography (CT), and occasionally magnetic resonance imaging is needed to confirm the diagnosis.

CASE DESCRIPTION

A patient presented to the emergency room with severe acute right upper-quadrant abdominal pain and thoracic back pain, improved in the left lateral decubitus position. She was awoken from sleep suddenly due to the severe back pain. She was afebrile with a blood pressure of 166/107 mm Hg, a heart rate of 133 beats per minute, a respiratory rate of 24 breaths per minute, and oxygen saturation of 99% in the emergency room. Laboratory results showed an initial serum lactate of 2.4 mmol/L, white blood cell count of 8 K/μL, hemoglobin of 14.9 g/dL, platelet count of 267 K/μL, international normalized ratio of 0.98, total bilirubin of 0.9 mg/dL, and lipase of 16 U/L. CT with aortic dissection protocol showed a distended gallbladder containing heterogenous attenuation. This prompted an ultrasound, which demonstrated heterogenous infiltration within the gallbladder lumen suspicious for malignancy or intraluminal hemorrhage (Figure 1).

Figure 1.

Ultrasound showing a distended gallbladder, with the left arrow pointing to the distended gallbladder wall and the right arrow pointing to the heterogenous infiltrate.

The patient was taken to the operating room within 18 hours of admission for laparoscopic cholecystectomy. The gallbladder was decompressed because of extreme distention and blood clots were evacuated. Prolonged adhesiolysis was performed. Due to the size of the cystic duct, it was controlled with a 0-PDS Endoloop. The postoperative course was uncomplicated, and the patient was discharged 3 days after presentation.

DISCUSSION

Hemorrhagic cholecystitis is a very rare complication of acute cholecystitis. It is mistaken for other conditions such as thoracic aortic dissection, as it can present with back pain, or acute cholecystitis, due to right upper quadrant abdominal pain with a positive Murphy’s sign.² It also presents with other generalized findings such as fever, leukocytosis, and gastrointestinal bleed. Most cases include an identifiable risk factor leading to the condition, such as nonsteroidal antiinflammatory or anticoagulant use.¹ Other reasons for a hemorrhage within the gallbladder include obstructive cholecystitis, trauma, percutaneous interventions, neoplasms, parasites, or bleeding disorders.³ The condition can also present in the setting of malignancy, cirrhosis, and renal failure.

A 2019 review identified only 30 reported cases of hemorrhagic cholecystitis between 1985 and 2018,⁴ and 45% of those cases were reported to occur in patients who were on anticoagulation therapy. Our patient did not have any of the typical risk factors and instead aortic dissection was suspected due to the initial emergency department presentation.

The initial evaluation is done through ultrasound. This may detect the presence of gallstones, smooth wall thickening >3 mm, marked focal wall irregularities, intraluminal membranes, and coarse intraluminal echos.⁵ These irregularities are the main distinguishing factors between acute and hemorrhagic cholecystitis. CT scans are used to confirm the diagnosis. Treatment is typically an open or laparoscopic cholecystectomy but can also include the less employed approach of a percutaneous cholecystectomy.⁶ Although our patient did not have any postoperative complications, this is not always the case. Hemorrhagic cholecystitis can present with complications due to perforation, necrosis, and potentially massive hemorrhage.¹

Hemorrhagic cholecystitis is a medical emergency with a high rate of morbidity and mortality. It presents with an acute onset of intense abdominal or back pain that may be mistaken for other conditions such as thoracic aortic dissection. This case highlights the importance of a high index of suspicion for hemorrhagic cholecystitis even in the absence of typical risk factors, such as anticoagulant use or trauma, and the importance of imaging for a timely diagnosis and surgical intervention.