Acute cholecystitis presenting with massive intra-abdominal haemorrhage

Abstract

Haemorrhagic cholecystitis is a known rare life-threatening complication of acute cholecystitis. In this case report, we describe clinical presentation and radiological findings of acute cholecystitis presenting with massive intra-abdominal haemorrhage. We present a case of a 57-year-old male presenting to the emergency department with clinical symptoms of acute cholecystitis. Initially, the patient was haemodynamically stable. Gallbladder could not be visualized by ultrasound. Computed tomography with IV contrast showed a large haematoma in the gallbladder fossa, with active extravasation of IV contrast. On angiography the bleeding was localized to a branch of the cystic artery, which was embolized using gelfoam material. The patient was taken to the operating room for an urgent laparotomy and cholecystectomy.

Hemoperitoneum secondary to haemocholecyst due to acute cholecystitis

“…Gallbladder bleeding due to cholecystitis is unusual because inflammation mainly causes vascular thrombosis. However, it can also cause damage to vessels' adventitia, weakening their wall and generating bleeding 4,5 . Furthermore, bleeding secondary to cholecystitis can be produced by ulceration and necrosis of the mucosa or by liver bed involvement when gallbladder perforation occurs 5 .…”

“…Bleeding can produce intravesicular clots that cause vesicular distension and acute cholecystitis typical clinical manifestations 1,2,4,5 . If it evolves, necrosis of the wall with vesicular perforation can occur, giving rise to acute abdomen secondary to hemoperitoneum 1,2,5 . Hemoperitoneum can also be secondary to erosion of the cystic artery or one of its branches 4,5 .…”

“…If it evolves, necrosis of the wall with vesicular perforation can occur, giving rise to acute abdomen secondary to hemoperitoneum 1,2,5 . Hemoperitoneum can also be secondary to erosion of the cystic artery or one of its branches 4,5 . Intravesicular blood can also advance towards the bile duct and obstruct it, which favors the development of cholangitis or, if it reaches the gastrointestinal tract, it can cause upper gastrointestinal bleeding clinical manifestations 1,2,3,5 .…”

“…Hemoperitoneum can also be secondary to erosion of the cystic artery or one of its branches 4,5 . Intravesicular blood can also advance towards the bile duct and obstruct it, which favors the development of cholangitis or, if it reaches the gastrointestinal tract, it can cause upper gastrointestinal bleeding clinical manifestations 1,2,3,5 . Table 1 compares our findings with those described in the literature.…”

“…Diagnosis is difficult and is usually intraoperatively established 1 . Ultrasound findings include gallbladder wall thickening or focal irregularities and presence of intraluminal echogenic material without posterior acoustic shadow [2][3][4][5] . Computed tomography shows high-density fluid within the gallbladder lumen, and contrast extravasation at early arterial phase can be demonstrated in case of significant active bleeding.…”