Gangrenous Cholecystitis as a Potential Complication of COVID-19: A Case Report

Acalculous Cholecystitis in COVID-19 Patients: A Narrative Review

Acute acalculous cholecystitis (AAC) represents cholecystitis without gallstones, occurring in approximately 5-10% of all cases of acute cholecystitis in adults. Several risk factors have been recognized, while infectious diseases can be a cause of cholecystitis in otherwise healthy people. Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has spread worldwide, leading to an unprecedented pandemic. The virus enters cells through the binding of the spike protein to angiotensin-converting enzyme 2 (ACE2) receptors expressed in many human tissues, including the epithelial cells of the gastrointestinal (GI) tract, and this explains the symptoms emanating from the digestive system. Acute cholecystitis has been reported in patients with COVID-19. The purpose of this review is to provide a detailed analysis of the current literature on the pathogenesis, diagnosis, management, and outcomes of AAC in patients with COVID-19.

Is conservative management a safe approach for patients with acute acalculous cholecystitis presenting with an acute abdomen?

Patients with acute acalculous cholecystitis (AAC) often present with acute abdominal symptoms. However, recent clinical studies have suggested that some patients with AAC and an acute abdomen, especially when caused by viruses or rheumatic disease, may not require cholecystectomy and that conservative treatment is adequate. Whether cholecystectomy is superior to conservative treatment for patients with AAC presenting with a severe acute abdomen is still uncertain. This was a case series study of AAC-related literature published between 1960 and 2022. In total, 171 cases (104 viral infection-associated AAC and 67 rheumatic disease-associated AAC) were included. The prognoses of patients receiving cholecystectomy or conservative treatment were compared. To account for confounding factors, etiological stratification and logistic regression were performed. The prognosis was similar for patients undergoing cholecystectomy and conservative treatment (P value .364), and virus infection-associated AAC had a better prognosis than rheumatic disease-associated AAC (P value .032). In patients with AAC caused by viruses or rheumatic disease, the acute abdomen can be adequately managed by conservative treatment of the underlying etiology and does not mandate surgical intervention.

Acute acalculous cholecystitis as a rare gastroenterological association of COVID-19: a case series and systematic review

Background and Aim

Acute acalculous cholecystitis (AAC) is an acute inflammatory disease of the gallbladder in the absence of cholecystolithiasis. It is a serious clinicopathologic entity, with a high mortality rate of 30-50%. A number of etiologies have been identified that can potentially trigger AAC. However, clinical evidence on its occurrence following COVID-19 remains scarce. We aim to evaluate the association between COVID-19 and AAC.

Methods

We report our clinical experience based on 3 patients who were diagnosed with AAC secondary to COVID-19. A systematic review of the MEDLINE, Google Scholar, Scopus, and Embase databases was conducted for English-only studies. The latest search date was December 20, 2022. Specific search terms were used regarding AAC and COVID-19, with all associated permutations. Articles that fulfilled the inclusion criteria were screened, and 23 studies were selected for a quantitative analysis.

Results

A total of 31 case reports (level of clinical evidence: IV) of AAC related to COVID-19 were included. The mean age of patients was 64.7 ± 14.8 years, with a male-to-female ratio of 2.1:1. Major clinical presentations included fever 18 (58.0%), abdominal pain 16 (51.6%), and cough 6 (19.3%). Hypertension 17 (54.8%), diabetes mellitus 5 (16.1%), and cardiac disease 5 (16.1%) were among the common comorbid conditions. COVID-19 pneumonia was encountered before, after, or concurrently with AAC in 17 (54.8%), 10 (32.2%), and 4 (12.9%) patients, respectively. Coagulopathy was noted in 9 (29.0%) patients. Imaging studies for AAC included computed tomography scan and ultrasonography in 21 (67.7%) and 8 (25.8%) cases, respectively. Based on the Tokyo Guidelines 2018 criteria for severity, 22 (70.9%) had grade II and 9 (29.0%) patients had grade I cholecystitis. Treatment included surgical intervention in 17 (54.8%), conservative management alone in 8 (25.8%), and percutaneous transhepatic gallbladder drainage in 6 (19.3%) patients. Clinical recovery was achieved in 29 (93.5%) patients. Gallbladder perforation was encountered as a sequela in 4 (12.9%) patients. The mortality rate in patients with AAC following COVID-19 was 6.5%.

Conclusions

We report AAC as an uncommon but important gastroenterological complication following COVID-19. Clinicians should remain vigilant for COVID-19 as a possible trigger of AAC. Early diagnosis and appropriate treatment can potentially save patients from morbidity and mortality.

Relevance for Patients

AAC can occur in association with COVID-19. If left undiagnosed, it may adversely impact the clinical course and outcomes of patients. Therefore, it should be considered among the differential diagnoses of the right upper abdominal pain in these patients. Gangrenous cholecystitis can often be encountered in this setting, necessitating an aggressive treatment approach. Our results point out the clinical importance of raising awareness about this biliary complication of COVID-19, which will aid in early diagnosis and appropriate clinical management.

A Surgical Perspective of Gastrointestinal Manifestations and Complications of COVID-19 Infection

The coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2, has quickly spread over the world since December 2019. COVID-19 is a systemic disease that can affect various organs throughout the body. Gastrointestinal (GI) symptoms have been reported in 16% to 33% of all patients with COVID-19 and in 75% of critically ill patients. This chapter reviews the GI manifestations of COVID-19 as well as their diagnostic and treatment modalities.

Acute acalculous cholecystitis caused by SARS-CoV-2 infection: A case report and literature review

Background

Emerging data indicate that gastrointestinal disorders, in addition to pulmonary dysfunction, are also hallmarks of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.

Case presentation

A 42-year-old man with maintenance hemodialysis developed high fever and dyspnea. He was positive for SARS-CoV-2 and was diagnosed with pneumonia. After treatment for SARS-CoV-2, his respiratory condition improved. However, he developed right upper quadrant pain with elevated inflammatory markers (white blood cells, 21,160/μL; c-reactive protein, 163.9 mg/L) on the 13th day. Abdominal computed tomography revealed acute acalculous cholecystitis. Percutaneous transhepatic gallbladder drainage (PTGBD) was performed together with antibiotic therapy, which resulted in improvement of symptoms. Laparoscopic cholecystectomy was performed 36 days after PTGBD.

Conclusion

We report a rare case of acute acalculous cholecystitis (AAC) following pneumonia caused by SARS-CoV-2 infection. We also conducted a literature search to characterize SARS-CoV-2-related cholecystitis. Infection with SARS-CoV-2 is an important trigger for AAC, and appropriate therapeutic alternatives should be cautiously selected according to individual cases.

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We experienced a case of acute acalculous cholecystitis (AAC) following COVID-19.

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We conducted a literature review to explore clinical features of COVID19 related AAC.

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SARS-CoV-2 infection should be considered as an important trigger for AAC.