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BMJ Case Rep. 2010; 2010: bcr01.2009.1534.
Published online Mar 15, 2010. doi:  10.1136/bcr.01.2009.1534
PMCID: PMC3028007
Unusual presentation of more common disease/injury
A 3 cm sealed pyloric perforation discovered during emergency cholecystectomy
Eleanor J Turner,1 Eoghan R T C Owen,2 and Kalakata Reddy2
1Epsom General Hospital, Surgery, Dorking Road, Epsom KT18 7EG, UK
2East Surrey Hospital, Surgery, Canada Avenue, Redhill RH1 5RH, UK
Correspondence to Eleanor J Turner, ejhturner/at/yahoo.com
Abstract
The diagnosis of acute cholecystitis is made on clinical, haematological, biochemical and radiological grounds, and laparoscopic cholecystectomy is commonly performed in the emergency setting. We report a case in which a patient diagnosed with acute cholecystitis was found to have a sealed pyloric perforation at laparoscopy as well as cholecystitis.
Background
Both upper gastrointestinal perforation and acute cholecystitis are common surgical emergencies and it is therefore not surprising that it is possible to find both pathologies in the same patient. Here we report a case of a sealed pyloric perforation found during emergency cholecystectomy for cholecystitis.
We report a case of a woman in her mid 50s who presented with a 10 day history of colicky right upper quadrant pain radiating to the back which had been gradually improving over time but had not fully settled. She had been eating without problem. Past medical history included asthma, depression and breast reduction surgery, and she was otherwise fit and well. She took the oral medicine citalopram, and salbutamol and beclomethasone by inhalation. She was an ex-smoker and drank occasionally.
On examination she was apyrexial and was not hypotensive or tachycardic. Abdominal examination revealed a soft abdomen with tenderness in the right upper quadrant. The clinical impression was that of resolving cholecystitis. She was started on intravenous antibiotics and clear fluids.
Investigations
Blood tests showed a bilirubin of 20 μmol/l, alanine transaminase of 416 U/l, alkaline phosphatase of 78 U/l, and white cell count of 10.7×109/l.
Abdominal ultrasound showed a normal sized liver with no bile duct dilatation or focal lesion. The gallbladder was full of debris and one large gallstone measuring 1.1 cm was present. The wall of the gallbladder was inflamed, consistent with acute calculus cholecystitis. The common bile duct was not dilated and the pancreas was structurally normal.
Differential diagnosis
The patient was felt clinically to have had a resolving cholecystitis. However, upper gastrointestinal disease should also have been considered.
Three days following admission she was taken to theatre for a laparoscopic cholecystectomy. At operation there was no free fluid and she was found to have an inflamed tense gallbladder. The pylorus was adherent to the gallbladder. The pylorus was separated easily from the gallbladder and found to have a 3 cm perforation (fig 1). The perforation appeared punched out and there were no obvious chronic changes or fibrosis. The gallbladder was intact with no perforation. Cholecystectomy was performed and the pylorus was repaired using laparoscopic suturing and omental patch repair.
Figure 1
Figure 1
Laparoscopic image showing pyloric perforation following separation of pylorus and gallbladder. The gallbladder mucosa is intact.
The intact, thickened gallbladder was opened after removal and was found to contain sludge and stones (fig 2). Pathological examination confirmed a gallbladder wall which was 4–5 mm thick with intact mucosa. On microscopy the gallbladder showed acute on chronic cholecystitis. The pyloric biopsies revealed gastric antral mucosa with acute inflammation and benign ulceration. There was reactive atypia in the mucosal epithelial cells adjacent to the ulcer, but no evidence of neoplasia.
Figure 2
Figure 2
The opened gallbladder showing the area that the pyloric perforation had been adherent to, which measured 3 cm.
Outcome and follow-up
Postoperatively, the patient’s recovery was unremarkable and she was discharged after 1 week.
Acute cholecystitis is a common surgical emergency arising from gallstone disease. It is usually treated with rest, antibiotics and cholecystectomy, which can be immediate or delayed.
Perforated peptic ulcer is one of the complications of peptic ulcer disease and is still a common surgical emergency, though the incidence has decreased dramatically with the use of proton pump inhibitors. Usually upper gastrointestinal perforations present with an acute abdomen with features of peritonitis. Perforations are usually repaired though can be treated conservatively. Without surgery the natural history is for the perforation to become sealed off by surrounding structures (usually the omentum). Although upper gastrointestinal perforations are sometimes treated conservatively these tend to be in older patients who may not do well with an operation. Repair may be open or laparoscopic.1,2
Despite the two pathologies being very common there is little in the literature about the two pathologies coexisting. A previous case series has shown seven cases of perforated duodenal ulcer found during laparoscopic cholecystectomy in a retrospective study of 5539 patients who had undergone laparoscopic cholecystectomy for gallstone disease in a single unit.3 No other cases were found in the literature.
The case presented here is an unusual presentation of a pyloric perforation. It is possible that this was an incidental finding. However, the perforation was large and it is surprising if this did not cause symptoms itself. It is difficult to tell which caused the presentation, especially as the histology showed acute inflammation in both the pyloric biopsies and the gallbladder. However, it is possible that it was the cause of the presentation and was masquerading as cholecystitis. This case demonstrated how well the body can seal off such substantial perforations.
The case reminds us of the need to know how to deal with unexpected findings at laparoscopy. It reminds us that it is necessary to train ‘general surgeons’ in the world of super-specialisation.
Learning points
  • It is important not to be led entirely by scans and to use clinical judgment when making a diagnosis of acute cholecystitis.
  • Upper gastrointestinal perforations may not always present with peritonitis.
  • Multiple pathologies may be found at operation.
  • It is important to be able to deal with the unexpected at operation.
Footnotes
Competing interests: None.
REFERENCES
1. Siu WT, Leong HT, Law BK, et al. Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg 2002; 234: 313–9. [PubMed]
2. Sanabria AE, Morales CH, Villegas MI. Laparoscopic repair for perforated peptic ulcer disease. Cochrane Database Syst Rev 2005; 19(4): CD004778. [PubMed]
3. Alexakis N, Konstadoulakis MM, Leandros E, et al. Sealed perforated duodenal ulcer discovered during elective laparoscopic cholecystectomy. Endoscopy 2004; 36: 342–3. [PubMed]
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