Hemoperitoneum from Acute Perforated Cholecystits

Gallbladder perforation has a reported mortality rate of up to 42% and occurs in 2-15% of cases of acute cholecystitis. Hemoperitoneum as a result of gallbladder perforation is even less prevalent, and has been reported in a limited amount of case reports. Most of the reported cases occur in patients who are anticoagulated or have a bleeding disorder. Treatment requires prompt operative intervention with broad spectrum antibiotics, often with the patient requiring an open operation. Herein is presented a case of a patient who presented to the ED with a hemoperitoneum arising from a gallbladder perforation. A 70 year old male with a past medical history of hypertension and benign prostatic hypertrophy, not on any anticoagulation complaining a 2-3 day history of epigastric and right upper quadrant abdominal pain presented to the ED at Northeast Georgia Health System Braselton. The patient had an urgent CT scan performed by his primary care physician based upon a 24 hour history of worsening abdominal pain from the past 2-3 day. The resulting imaging study showed hemoperitoneum in the right upper quadrant. The patient was sent to the Emergency Department where was afebrile with vitals of heart rate 88, blood pressure 155/81, and respiratory rate 14. The ED staff obtained labs and his hemoglobin was 13.2. Once the surgical service had been notified he was emergently taken to the OR for a diagnostic laparoscopy. On laparoscopy, the patient was found to have extensive hemoperitoneum originating from a perforation in the gallbladder fundus. The patient was treated with a laparoscopic subtotal fenestrating cholecystectomy with drain placement. This was performed because there was a significant amount of inflammation around the base of the infundibulum and the gallbladder was gangrenous. It was thought that further dissection around in this area could be more likely to cause a common duct injury and that the risk of bile leak would already be high. The bleeding was determined to be from the area of the gallbladder that has been perforated by the stone that had eroded thought the infundibulum and that had been controlled with cautery. Surgical gauze and powder were placed around the liver bed as an additional hemostatic agent as well. Thus, subtotal fenestrating cholecystectomy without attempts to close the cystic duct lumen appeared to be the safest option for treatment of this clinical situation. The patient did well in the post op course. His post op hemoglobin was 12. The patient did not require a blood transfusion and was managed on the postoperative surgical floor. He did not require an ICU stay. He did develop the expected bile leak but the drain placed at the time of the operation had it well controlled. An ERCP with stent placement was attempted twice at our institution but our gastroenterology service was unsuccessful in cannulating the ampulla. The patient was discharged on post op day 5. ERCP attempts and urinary retention requiring foley catheter placement are what result in the patient needing to stay up until post op day 5. The patient was subsequently referred to a tertiary care facility where their gastroenterology service was successful in performing an ERCP and placing a stent. The bile leak resolved in 5-7 days and the surgical drain was removed after the leak had sealed in the office with no issues. The patient required readmission for a fever with positive blood cultures revealing Raoultella orinithinolytica, this was successfully treated with IV and oral antibiotics by the ID service. Biliary manipulation is the likely source of this pathogen. The patient was seen 1 month after drain placement and had no issues at that time (Figures 1–4). This case demonstrates two uncommon scenarios that are a result of cholecystitis, gallbladder perforation and hemoperitoneum. Most cases that have described such scenarios as occurring in patients who had either been anticoagulated or had a bleeding disorder. Laparotomy has also been employed in several of the case reports for successful management of the patient. The patient was promptly sent to the ED by the physician who ordered the CT scan and the ED staff notified the surgeon on call in a timely fashion. These factors likely aided in the patient being able to avoid a blood transfusion, ICU stay, and to perform the operation laparoscopically. Employing the use of a subtotal fenestrating cholecystectomy with drain placement technique and accepting a bile leak also likely allowed us to avoid an open conversion, as well as a duct injury. With the ability to control most bile leaks with ERCP or PTC, implementation of a subtotal fenestrating cholecystectomy with drain placement at the time of a difficult cholecystectomy can potentially reduce open conversions in the future. Avoiding open conversion and