Atraumatic spontaneous hemorrhagic cholecystitis

Hemorrhagic Cholecystitis in a Patient Under Anticoagulant and Antiplatelet Therapy: A Case Report

Hemorrhagic cholecystitis is an uncommon presentation of acute cholecystitis. Due to its etiology and unspecific clinical data, it is an entity that represents a diagnostic challenge. We present a case of a 70-year-old male with diabetes type 2, hypertension, and chronic kidney disease with hemodialysis, who attended the emergency department with sudden-onset abdominal pain in the epigastrium. The patient presented no additional symptoms, a normal electrocardiogram, but due to the characteristics of the pain and elevated troponin I, emergency medicine specialists considered an acute coronary syndrome and initiated antiplatelet and anticoagulant therapy. Due to persistent abdominal pain, a decrease in hemoglobin, and the onset of arterial hypotension, a computed tomography (CT) scan was performed, which revealed perforation of the gallbladder, apparent hemorrhagic cholecystitis, and hemoperitoneum. The patient underwent emergent surgery, where CT findings were confirmed. In our case, the suspicion of hemorrhagic cholecystitis arose until the clinical case was advanced, after receiving anticoagulant and antiplatelet therapy, and it was confirmed during surgery and with histopathology. This concludes that hemorrhagic cholecystitis is a rare disease and difficult to diagnose. Therefore, studies should focus on clinical presentation and risk factors (e.g., trauma, malignancy, renal failure, cirrhosis, and anticoagulation therapy) to promote early diagnosis and avoid complications.

A Case of Hemorrhagic Cholecystitis in a Patient on Apixaban After COVID-19 Infection

BACKGROUND Hemorrhagic cholecystitis is a rare cause of abdominal pain, which can result from malignancy, bleeding, or trauma. The presentation, which includes right upper-quadrant pain, nausea, and vomiting, can overlap with other disease states, thereby rendering the diagnosis challenging. CASE REPORT We describe a patient taking apixaban wo had paroxysmal atrial fibrillation with history of joint pain on long-term steroids who developed hemorrhagic cholecystitis following an episode of pneumonia secondary to SARS-CoV-2 virus (COVID-19) infection. The hospital COVID-19 pneumonia protocol included the administration of steroids and symptomatic care. Following discharge, he presented to our hospital with a sudden onset of severe abdominal pain and distention accompanied by elevated liver enzymes and a low hemoglobin level of 78 g/L. Magnetic resonance cholangiopancreatography revealed a distended gallbladder and intraluminal layering, early subacute blood products, and increased wall thickness, which was thought to represent non-calcular hemorrhagic cholecystitis. Furthermore, a stable 18×16×20 mm cyst in the tail of the pancreas was also located posteriorly, with indentation to the splenic vein. The patient was managed conservatively, and the pain subsided on day 3 after admission. CONCLUSIONS Hemorrhagic cholecystitis is rarely reported with the use of the direct oral anticoagulants (DOACs). In our case the combination of a recent COVID-19 hospitalization, steroid use, and possible pancreatic cancer (CA 19-9 288.4 kU/L) may have contributed to such incidence in the setting of apixaban utilization; however, it is not possible to make definitive correlations. Investigating hemorrhagic cholecystitis in the setting of DOAC use in patients with multiple risk factors such as those that existed in our patient is imperative for proper diagnosis and management.

Emergent laparoscopic surgical intervention for perforated hemorrhagic cholecystitis with hemodynamic instability

Hemorrhagic cholecystitis is a rare diagnosis that closely mimics acute cholecystitis. Physical examination, laboratory studies and, in particular, computed tomography imaging allow for rapid diagnosis, stabilization and emergent surgical intervention. We describe our experience with three patients requiring emergent surgical intervention for hemorrhagic cholecystitis with unique clinical features including decreased platelet function due to liver cirrhosis, dual antiplatelet therapy and intraoperative finding of cholecystohepatic communication. Furthermore, we provide video recordings of two cases highlighting the severity of the disease. All presented patients were hemodynamically unstable and showed peritoneal signs on exam. Laboratory studies revealed moderate anemia and leukocytosis, while computed tomography suggested hemorrhage in the gallbladder. All patients required blood transfusions during their care and underwent laparoscopic cholecystectomy. Hemoperitoneum and gallbladder perforation were confirmed intraoperatively. Patients fully recovered without significant postoperative complications due to expedited operative management.

Gallbladder hemorrhage–An uncommon surgical emergency: A case report

BACKGROUND

Gallbladder hemorrhage is a life-threatening disorder. Trauma (accidental or iatrogenic such as a percutaneous biopsy or cholecystectomy surgery), cholelithiasis, biliary tract parasitosis, vasculitis, vascular malformations, autoimmune and neoplastic diseases and coagulopathies have been described as causes of hemorrhage within the lumen of the gallbladder. The use of non-steroidal anti-inflammatory drugs and anticoagulants may represent a risk factor.

CASE SUMMARY

We report the case of a 76-year-old male patient. An urgent contrast computed tomography scan demonstrated relevant distension of the gallbladder filled with hyperdense non-homogeneous content. The gallbladder walls were of regular thickness. Near the anterior wall a focus of suspected active bleeding was observed. Due to the progressive decrease in hemoglobin despite three blood transfusions, this was an indication for urgent surgery.

CONCLUSION

Early diagnosis of this potentially fatal pathology is essential in order to plan a strategy and eventually proceed with urgent surgical treatment.

Hemorrhagic Cholecystitis: A Rare Cause of Melena

Hemorrhagic cholecystitis -- a rare cause of hemobilia and melena -- is an atypical presentation of calculous cholecystitis, associated with significant morbidity and mortality. A 75-year-old woman with multiple comorbidities, who was undergoing dual antiplatelet therapy, presented with symptoms of acute cholecystitis. Two days later, she developed melena and symptoms of obstructive jaundice. Following radiological evaluation, a diagnosis of hemorrhagic cholecystitis was made. The patient was managed conservatively with IV antibiotics and blood transfusion in the initial period (clopidogrel was withheld); an interval cholecystectomy was performed six weeks later. Hemorrhagic cholecystitis is a rare complication of acute cholecystitis, and its diagnosis is challenging as it mimics various other hepatopancreaticobiliary diseases. Management options include early surgery or conservative management at the initial stage, followed by interval cholecystectomy.

Surgical case report-acalculous hemorrhagic cholecystitis

Haemorrhagic cholecystitis is a seldom seen cause of right upper quadrant pain that can result in gallbladder rupture, massive intraperitoneal haemorrhage and death if untreated. Haemorrhagic cholecystitis is usually seen in the presence of cholelithiasis, malignancy, trauma and coagulopathies. Here, we present the unusual case of an elderly man presenting with acalculous haemorrhagic cholecystitis, who was successfully treated with laparoscopic cholecystectomy. We review the radiological and laparoscopic findings of haemorrhagic acalculous cholecystitis. This case highlights the importance of prudent use of radiological imaging to differentiate haemorrhagic cholecystitis from alternate pathology and early surgical intervention to avoid massive intraperitoneal haemorrhage and the high mortality with which it is associated.