Laparoscopic management of massive intraperitoneal haemorrhage caused by an acute gallbladder perforation.

Laparoscopic cholecystectomy is the gold standard for managing the treatment of patients with symptomatic gallstone disease. Certain patients with acute cholecystitis will develop gallbladder perforation (GP). Furthermore, massive intraperitoneal haemorrhage following perforation is a rare complication. The high morbidity and mortality rates associated with this condition are due to delays in the diagnosis and treatment since signs and symptoms of perforation do not differ significantly from those of uncomplicated cholecystitis. Severe inflammation and haemodynamic instability necessitate exploratory laparotomy in many patients. To the best of our knowledge, no study had described laparoscopic completion cholecystectomy for massive intraperitoneal haemorrhage caused by an acute GP. Laparoscopy can be an option for the management of these patients, in selected cases and with available expertise.

INTRODUCTION

Massive intraperitoneal haemorrhage due to gallbladder perforation (GP) is one of the most severe and life-threatening complications of acute cholecystitis. Due to the high mortality that can be caused by a delay in the correct diagnosis and application of appropriate surgical treatment, GP represents a special diagnostic and surgical challenge.[1] Laparoscopic cholecystectomy (LC) has dramatically changed the treatment of patients with symptomatic gallstone disease. Acute GP is a potentially fatal complication of gallstones. Furthermore, coincident intraperitoneal haemorrhage was previously considered to be a contraindication for LC since it was believed to be a life-threatening complication as well as the most common cause of conversion. Here, we present the first reported case of successful LC in a patient who was affected by alcoholic liver cirrhosis with multiple hepatocellular carcinomas and who developed an acute GP with massive intraperitoneal haemorrhage and spillage of stones.

CASE REPORT

A 58-year-old male visited our hospital, presenting with acute abdominal pain and a deteriorating general condition. From his history, we found that the patient had liver cirrhosis due to alcohol abuse and multiple hepatocellular carcinomas. He underwent 4 rounds of transcatheter arterial chemoembolisation. Physical examination revealed a distended abdomen with tenderness in the right upper quadrant and signs of emergent peritoneal irritation. On admission, blood pressure, temperature and pulse were 85/60 mmHg, 36.5°C and 90 beats/min, respectively. Laboratory studies revealed white blood cells 10.6 × 103/μl (4–10 × 103/μl), haemoglobin 8.4 g/dl (3–17 g/dL), prothrombin time 15.8 s (8.1–12.9 s), activated partial thromboplastin time 36.6 s (27–40 s), blood urea nitrogen 27.2 mg/dL (4–20 mg/dL), creatinine 2.32 mg/dL (0.7–1.4 mg/dL), total bilirubin 1.01 mg/dL (0.22–1.4 mg/dL) and albumin 1.725 g/dL (3.8–5.0 g/dL) (Child-Pugh B). Abdominal computed tomography (CT) imaging showed a large haematoma in the peritoneal cavity, with active extravasation of contrast material and gallstones spillage in the gallbladder fossa [Figure 1a–c]. The patient was taken to the operating room for urgent LC [Figure 2a–c]. There was no perioperative complication.

Figure 1

(a) Axial non-enhanced computed tomography scan shows extensive high-density ascites containing free, spillage gallstones (white arrows) and cystic duct stone of the gallbladder (black arrow). (b) Axial view. (c) Coronal view. Enhanced computed tomography of the abdomen. Computed tomography images showings active extravasation of IV contrast material inside the gallbladder (white arrows) with a defect on the wall (black arrows) indicating active bleeding and surrounding haemoperitoneum

Figure 2

Laparoscopic view. (a and b) A large quantity of blood and free gallstones were observed. (c) The gallbladder was avulsed from its cirrhotic liver bed due to haemorrhage and laparoscopic cholecystectomy was performed

DISCUSSION

GP was first reported by Duncan in the year 1889. The reported rate of perforation development in patients with acute cholecystitis was 2%–11%.[2] Perforation can develop early during acute cholecystitis but can also occur several weeks after onset. Intraperitoneal haemorrhage caused by cholecystitis is extremely rare since the inflammation is thought to cause vascular thrombosis. However, inflammation may also cause damage to the adventitia with thrombosis of the vasa vasorum, thereby resulting in weakening of the vessel wall.[3]

Diagnosis may be difficult due to the varied clinical presentation. An arterial phase contrast-enhanced CT may demonstrate active extravasation of contrast material into the gallbladder lumen, which confirms the diagnosis. Measurement of the attenuation values should have led to the diagnosis of blood in as well as around the gallbladder, supporting the correct diagnosis.

Emergency laparotomy is appropriate for the management of acute GP patients, particularly those with findings of massive haemopertitoneum. Nevertheless, LC has become a preferred and acceptable choice, even in the most difficult situations associated with complicated gallstone disease. It can be technically challenging with haemoperitoneum caused by GP, especially coexisting cirrhosis of the liver. At the inception of laparoscopic surgery, cirrhosis was listed either as an absolute or as a relative contraindication. However, with increased experience with laparoscopy, several studies across the world have demonstrated that LC is safe and effective as well as exhibit fewer complications compared to open cholecystectomy.[4] In Child-Pugh A and B cirrhotic patients who undergo LC, the overall mortality rate does not statistically differ from that of the general population.[5]

Early diagnosis and surgical intervention are central to decreasing mortality and morbidity in the management of massive intraperitoneal haemorrhage caused by an acute GP. To the best of our knowledge, this is the first reported case of free intraperitoneal bleeding caused by acute GP that was treated successfully using LC.

CONCLUSION

GP is a rare condition that should be diagnosed and treated as soon as possible to decrease morbidity and mortality. The most important diagnostic tool is an early CT scan, followed by cholecystectomy on an emergency basis. LC can be considered an option for the treatment of intraperitoneal haemorrhage caused by acute GP when performed by an experienced surgeon.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.