Acute Hemorrhagic Cholecystitis with Large Hemoperitoneum: Treatment with Microcoil Embolization and Subsequent Cholecystectomy
74 years old white male with history of atrial fibrillation and on coumadin was referred from an outside hospital with a 5 days history of abdominal pain, nausea and vomiting followed by 2 days of severe right upper quadrant pain. He experienced no hematemesis or melena. His physical examination was significant for abdominal tenderness, particularly in the right upper quadrant and epigastric region. Hepatic panel revealed markedly elevated AST, ALT, and total bilirubin. Of greater clinical concern, however, laboratory values showed a significant drop in hemoglobin at 6.4 compared to 12.3 at outside hospital. Outside CT abdomen and pelvis study reported right upper quadrant hematoma and hemoperitoneum around the liver and spleen. In addition, there was report of a 1 cm gallstone impacted at the gallbladder neck with suggestion of erosion of the gallbladder wall. An ultrasound was performed at our institution and demonstrated a diffusely heterogeneous gallbladder with intraluminal blood products as well as thickened, discontinuous wall suspicious for perforation. There was no sonographic evidence of cholelithiasis on ultrasound, which was likely obscured by intraluminal hemorrhage, and doppler evaluation showed no evidence of active bleeding. An arteriography was requested to identify the source of the bleeding. From a right femoral approach, a 5 French Mickelson catheter was used to catheterize the celiac trunk and common hepatic artery. The cystic artery harboured two small pseudoaneurysms with no visible contrast extravasation. The Mickelson catheter was exchanged for a 4 French cobra C2 Glidecath introduced into the origin of the cystic artery. A 3 French Renegade microcatheter was then advanced through the guiding catheter and two 2mm X 3mm and two 2mm X 4mm InterLock microcoils were deployed in the proximal cystic artery. This resulted in successful exclusion of both pseudoaneurysms. Subsequent open cholecystectomy performed same day confirmed hemorrhagic cholecystitis with rupture of the gallbladder and large hematoma eroding into the right lobe of the liver. Approximately 1.5 liters of blood was removed during surgery. A gallbladder fossa drain was placed and the patient recovered in the intensive care unit. He was discharged with no residual symptoms. However, the patient came back seven weeks later with fever and chills. Repeat CT scan of the abdomen and a cholangiogram through the indwelling gallbladder fossa drain revealed an unresected base of the gallbladder containing the original gallstone. Review of the operative report from surgery discussed a technically challenging case with poor intraoperative visualization of the gallbladder from large pericholecystic hemorrhage, which likely contributed to the incomplete cholecystectomy. The patient was later scheduled for elective definite cholecystectomy and reported asymptomatic till date.
We report two cases of hemorrhagic cholecystitis with arteriographic findings of cystic artery pseudoaneurysms that were successfully embolized using microcoils, facilitating subsequent cholecystectomy. Both cases had unusual presentation of gallbladder rupture with hemoperitoneum, the latter of which was atypical occurring without the presence of gallstones.
Radiographic imaging plays a key role in identifying hemorrhagic cholecystitis. Frequently, ultrasound, CT, and MRI will demonstrate imaging features seen with classical cholecystitis including gallbladder wall thickening, gallstones, and pericholecystic fluid/infiltration. The most specific imaging finding for hemorrhagic cholecystitis is the identification of a cystic artery pseudoaneurysm. Contrast enhanced CT scan will demonstrate the densely enhancing pseudoaneurysm in the gallbladder lumen as well as detect active contrast extravasation. Ultrasound Doppler imaging can also reveal cystic artery pseudoaneurysm and help orient the investigation in the right direction. Dense gallbladder content is typically seen with hemorrhagic cholecystitis and may be misinterpreted as biliary sludging. Ultrasound will show echogenic debris and CT will show dense material. MRI, however, will allow differentiation from sludge by demonstrating blood product signal (hyperintense T1 and isointense/hypointense T2). Another potential pitfall is agglomerated blood inside the gallbladder may mimic a mass. Doppler analysis is useful to identify blood flow within the mass if it is a solid vascular lesion. It is important to be aware that on sonography, acute extravasation of blood between clot interstices can mimic blood vessels inside a mass (“pseudo-artery” sign), leading to the wrong diagnosis. Timely diagnosis of this rare and potentially fatal entity is critical. Arteriorgraphy is the most sensitive modality to identify the source of bleeding and has the advantage of offering minimally-invasive therapeutic option concomitantly. The literature reports up to 90% sensitivity for arteriography in detecting the source of hemobilia. Therefore, once the diagnosis of a hemorrhagic cholecystitis is suspected, a diagnostic and therapeutic arteriography should be part of the management algorithm. This should be followed by definitive treatment consisting of a cholecystectomy with ligation of the cystic artery. Pre-cholecystectomy embolotherapy has several reported advantages such as hemodynamic stabilization of patient with rapid cessation of hemorrhage. In addition, it allows additional time for preoperative surgical planning and helps minimize operative bleeding loss during surgery. Subsequent cholecystectomy is usually performed on the same or the day following the embolization procedure because of the theoretical fear that the occluded cystic artery will lead to more gallbladder ischemia and gangrene. However, after embolotherapy some patients had cholecystectomy up to 10 days later with no obvious reported complication linked to this delay. For patients who are not surgical candidates, embolization of the bleeding cystic artery followed by percutaneous cholecystostomy is an alternative option.
Classical symptoms of hemobilia are often absent and therefore it is important to consider the prospect of hemorrhagic cholecystitis in patients presenting with biliary symptoms associated with gastrointestinal bleeding, unexplained upper abdominal hemoperitoneum, or imaging findings suggestive of pericholecystic or gallbladder blood products. Once identified, a two-step therapeutic approach is recommended with embolization of the culprit vessel to stop the bleeding and stabilize the patient for subsequent cholecystectomy, which remains the ideal definitive treatment in surgical candidates.