Article, Surgery

Delayed necrotizing acalculous cholecystitis after multiple trauma

Case Report

Delayed necrotizing acalculous cholecystitis after multiple trauma

Abstract

This is a case report of a necrotizing acalculous cholecystitis 7 weeks after multiple orthopedic trauma successfully treated by operative intervention.

A 32-year-old man presented to the surgical admissions unit with a 2-day history of constant right upper quadrant pain with radiation into the back, exacerbated by movement and inspiration. This was associated with nausea and vomiting, and feeling feverish. He denied any other symptoms. Seven weeks prior the patient had been involved in a motorbike accident, resulting in a fractured pelvis and bilateral radius and ulna fractures. These were successfully treated by open reduction and internal fixation by the Orthopedic surgeons. Cross-sectional abdominal imaging at that time revealed no other injuries. The patient had made a successful recovery and had been discharged. He had remained on bed rest at home, well, and symptom-free until the current presentation. He had no other significant medical history. His only regular medication on presentation was paracetamol, diclofenac, and tramadol. He was a nonsmoker and only consumed a small amount of alcohol.

On examination, the patient was pyrexial at 38?C; tachypneic, with a sinus tachycardia of 110 beats per minute; and had a blood pressure of 100/70 mm Hg. Abdominal examination demonstrated localized peritonism in the right upper quadrant with a positive Murphy sign. Respiratory examination was unremarkable. Blood tests on admission revealed neutrophilia (white blood cell count, 15.6 x 109/L; neutrophils, 13.31 x 109/L). Liver function test results, renal function, and serum amylase were all normal. Arterial blood gas analysis demonstrated a compensated metabolic acidosis, with a base excess of -5. Erect chest x-ray demonstrated no pneumoperitoneum and was otherwise unremarkable. The initial working diagnosis was acute cholecystitis with sepsis, and the patient was fluid resuscitated, catheterized, and started on appropriate Intravenous antibiotics. An urgent abdominal ultrasound scan was requested.

Abdominal ultrasound demonstrated a distended gall-

bladder with no stones, free fluid around the liver, and a collection adjacent to the liver and a loop of small bowel in

the right upper quadrant. In view of the history of trauma, an abdominal computed tomographic scan was performed to rule out hepatic involvement. This demonstrated a distended gallbladder with extensive fluid and Inflammatory changes around the hepatic flexure, extending through the transverse mesocolon, which was thought to suggest colonic contusion. Based on this, a decision was made to proceed to emergency laparoscopy. Laparoscopy was performed using the open Hassan insertion. This demonstrated multiple adhesions in the right upper quadrant and a gangrenous gallbladder, closely adherent to the transverse colon. A decision was made to convert to a laparotomy. After freeing the adhesions, this confirmed the finding of a gangrenous gallbladder, which had perforated; however, the colon was undamaged and viable. A cholecystectomy was performed with a thorough lavage and a drain inserted in the Subhepatic space. The patient underwent an uncomplicated postoperative recovery. The first postoperative day was spent on the high dependency unit, thereafter transferred to standard-level care. The drain was removed after 48 hours, with no evidence of bile leak. The patient was discharged on the sixth postoperative day. The patient remains well on follow-up at

2 months postdischarge.

Acute acalculous cholecystitis is a serious and potentially lethal condition accounting for about 2% to 15% of the cases of acute cholecystitis [1]. It usually occurs in the critically ill patient, with a mortality rate between 15% and 50%. Common risk factors include major trauma, burns, recent surgery, sepsis, and prolonged total parenteral nutrition [1]. Other published associations include Salmonella infection, leptospirosis, viral hemorrhagic fever, AIDS, diabetes mellitus, vasculitis, and radiofrequency ablation of liver tumors. Acalculous cholecys- titis secondary to major trauma usually occurs in critically ill patients in the acute setting [2]. As far as the authors are aware, this is the first reported case of acalculous cholecystitis presenting at such an interval after trauma.

The pathogenesis of this condition is largely unknown; however, contributing factors included biliary stasis due to reduction in cholecystokinin-induced gallbladder mobility secondary to reduced oral intake and increased bile viscosity. Ischemia of the gallbladder due to Splanchnic vasoconstriction secondary to the systemic inflammatory response and subsequent reperfusion injury is likely to contribute. It is not readily apparent why this patient should develop acalculous cholecystitis 7 weeks after significant trauma. Contributing

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factors could include immobility and regular opiate analgesia [3]. Opiate analgesia has been implicated in biliary stasis by inhibiting excitatory neurotransmission in ganglia and neuro- muscular junction in the gallbladder [4].

Acalculous cholecystitis requires prompt assessment and treatment because of a more fulminant course than a calculous disease, with a higher incidence of gangrene and perforation. Ultrasonography is usually the first examination done in these patients and may identify biliary sludge, thickened gallblad- der wall, or pericholecystic fluid. Computed tomographic scan is reserved for those patients with negative ultrasound findings or other concerns. Acalculous cholecystitis is unlikely to respond to conservative treatment; therefore, emergency cholecystectomy represents the definitive treat- ment of choice. This can be performed laparoscopically; however, this is contraindicated in gangrenous/perforated gallbladders. Percutaneous ultrasound-guided cholecystost- omy remains the alternative option for high-risk patients.

Christopher D. Mann MRCS, BSc Matthew S. Metcalfe FRCS, MD Christopher P. Neal MBChB, BSc Gavin S. Robertson FRCS, MD

Department of Surgery, university hospitals of Leicester Leicester Royal Infirmary, Leicester LE1 5WW, UK E-mail address: [email protected]

doi:10.1016/j.ajem.2007.09.017

References

  1. Yasuda H, Takada T, Kawarada Y, et al. Unusual cases of acute cholecystitis and cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:98-113.
  2. Pelinka LE, Schmidhammer R, Hamid L, Mauritz W, Redl H. Acute acalculous cholecystitis after trauma: a prospective study. J Trauma 2003;55(2):323-9.
  3. Flancbaum L, Majerus TC, Cox EF. Acute posttraumatic acalculous cholecystitis. Am J Surg 1985;150(2):252-6.
  4. Guarraci FA, Pozo MJ, Palomares SM, Firth TA, Mawe GM. Opiod agonists inhibit excitatory neurotransmission in ganglia and at the neuromuscular junction in Guinea pig gallbladder. Gastroenterology 2003;122(2):340-51.