Gallbaldder perforation causing a subcutaneous abscess.

INTRODUCTION: This is a report of a rare case of an old woman with a large round mass in the right hypochondrium that was proven to be an abscess. PRESENTATION OF CASE: A 82-year old woman with a firm round mass in the right hypochondrium was admitted for evaluation. The abdominal CT showed an abscess produced by a gallbladder perforation, and a gallstone impacted at the Hartmann's pouch. DISCUSSION: The abscess was treated with a transcutaneous paracentesis, while the stone passed to the gastrointestinal tract through a cholecystoenteric fistula, without causing any further problems.
CONCLUSION: Gallbaldder perforation can rarely create a subcutaneous abscess especially in thin, elder subjects. Abscess drainage is the first line of treatment.

Case report

An 82-year-old woman was admitted on an emergency basis, with a protruding painless round mass in the right upper abdominal quadrant, with anorexia and fatigue for the previous 2 weeks. Her medical history included bronchial asthma, and hypertension.

At physical examination a firm, immobile abdominal mass was revealed under the right subcostal margin with a mild tenderness upon palpation of the right hypochondrium (Fig. 1). A computed tomographic (CT) scan was performed which showed a 10.5 cm × 7 cm × 7 cm well circumscribed cystic lesion originating from the right rectus abdominis muscle. The lesion communicated intra-abdominally with the margin of the right hepatic lobe and the gallbladder fundus, whereas a 2 cm gallstone was impacted at the Hartmann's pouch (Figs. 2 and 3). The duodenal wall was attached to the Hartmann's pouch. Upon admission the patient had a hematocrit of 28.0, a leukocyte count of 17.550 μl−1 and a total bilirubin level of 0.44 mg/dL. The patient was placed on broad spectrum antibiotics.

Fig. 1

An 82-year-old woman was admitted with a protruding painless round mass in the right upper abdominal quadrant.

The patient underwent transcutaneous paracentesis at the protuberant portion of the mass under sonographic guidance. One liter of purulent exudate was sucked and a 14F Nelaton tube was left in place to drain the collection. The following 2–3 days one more liter of exudate was drained and the mass started to shrink. The patient was placed on liquid diet. CEA levels and CA 19-9 serum levels of the patient were within normal range. At the sixth day the mass had substantially reduced in size and the Nelaton tube was removed. Four days later the patient complained for an episode of abdominal cramps and diarrhea. A sequential abdominal CT showed the collection of the right rectus abdominis muscle almost completely drained, with a small remaining cystic lesion communicating with the gallbladder fundus. In this CT a biliary–duodenal communication was certified, while the gallstone had disappeared, probably having passed to the gastrointestinal tract (Fig. 4). Four days later the patient was discharged in good general condition. At present, 6 months later, the patient is at home in excellent condition and has gained 5 kg of body weight, while the hematocrit has returned to normal.

Fig. 4

A sequential CT showed the collection of the right rectus abdominis muscle almost completely drained, with a small remaining cystic lesion communicating with the gallbladder fundus. A biliary–duodenal communication was also shown, while the gallstone had disappeared.

Discussion

Gallbladder perforation is a serious but rare complication of acute cholecystitis. There is a limited number of cases reported in the literature. In the majority of cases it is caused by acute cholecystitis, usually in the gallbladder fundus, which has the least blood supply. In general, if the perforation occurs in the fundus, the omentum is less likely to protect the perforation and the bile leaks into the peritoneal space. If the perforation occurs in the infudibulum, the omentum or other adjacent tissues are protective, and plastron or pericholecystic abscess forms.

Cholecystoduodenal or cholecystoenteric fistula is a well-established complication of acute cholecystitis. It occurs when the acutely inflamed gallbladder (especially when a stone is impacted at the Hartmann's pouch) becomes adherent to adjacent stomach, duodenum, or colon and necrosis develops at the site of one of these adhesions, with resultant perforation into the gut lumen. This decompression usually allows the acute disease to resolve. If the gallstones are relatively small they may pass through the ileocecal valve without any further sequela. The concomitant perforation of the gallbladder at its fundus and at the Hartmann's pouch to the adjacent intestine, however, is a very rare event, with only one case reported in the literature so far.

This case illustrates a patient who has developed gallbladder fundus perforation after an episode of acute cholecystitis, and a cholecystoduodenal fistula. The pus collection from the subhepatic space intruded through the fascia to the muscular planes and created a large subcutaneous abscess. It is remarkable that the mass was painless and the patient was afebrile. Moreover, the loss of weight and the evident cachexia led our differential diagnosis toward malignant disease at the beginning. However, the CT images were diagnostic: the gallbladder, severely inflamed perforated at its fundus, and a communication between the Hartmann's pouch and the duodenum was created, through which the stone passed to the gastrointestinal tract. The stone passage caused some gastroenteric complaints, but evidently passed through the ileocecal valve to the large bowel.

Conflict of interest

The authors have no conflict of interest.

Funding

There was no special funding for this manuscript.

Ethical approval

The authors have received written consent from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Author contributions

E. Misiakos was solely responsible for the study concept and design. He analysed and interpreted the data with N. Zavras and Ilias Brountzos and drafted the manuscript with N. Zavras and A. Charalampopoulos. He also supervised the study in association with A. Macheras, and critically revised the manuscript along with both A. Macheras and A. Charalampopoulos. Ilias Brountzos was also involved in the acquisition of data with Hra Tzepi.