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An 83-year-old, mildly demented rest home resident presented to the emergency department with a 2 day history of a right sided abdominal wall mass. He had a mechanical fall 2 days previously and landed on his right side and had attributed the mass to this. He had no symptoms apart from feeling bloated and not being able to pass wind for a day. He had passed a normal bowel motion the day before presentation. On abdominal examination there was an 11 × 4 cm mass in the right lower quadrant. It was firm in consistency, non-fluctuant and non-tender to touch. There was mild erythema over the area but no skin breaks. Chest radiograph was unremarkable. The abdominal film showed dilated small bowel and no large bowel could be seen. A computed tomography (CT) scan showed a thick walled gallbladder with multiple calculi and air present. There was also an extensive air and fluid collection in the layers of the abdominal wall and subcutaneous fat which arose from a perforation of the gallbladder. The patient was not a surgical candidate due to multiple comorbidities. The patient was treated with antibiotics and underwent a CT guided percutaneous cholecystostomy. Despite the radiological intervention and antibiotics the patient progressively deteriorated and died peacefully 5 days after admission.
Abscesses are commonly seen in surgical practice. They are usually straightforward to manage. We present an unusual and interesting case of a spontaneous gallbladder perforation presenting as an abdominal wall abscess.
An 83-year-old man presented to the emergency department with a 2 day history of a right sided abdominal mass. His medical background consisted of mild dementia, chronic obstructive pulmonary disease, osteoarthritis, hypertension, previous heavy alcohol intake, and limited mobility.
The patient lived in a rest home and was sent in by staff as they were concerned about a progressively enlarging mass in the right flank. He denied pain, fever, nausea and vomiting or weight loss. He had never had abdominal surgery in the past. The patient had a mechanical fall 2 days before admission in which he landed on his right side. He thought the mass was related to this. The patient said his last bowel motion was the day before presentation and it was normal. However, since then he says he has not been able to pass wind and he felt bloated.
On examination the patient was a thin man. He appeared comfortable. He had a temperature of 36.6°C, heart rate of 90 beats/mine, a blood pressure of 120/50 mm Hg, and a respiratory rate of 18. Cardiovascular and respiratory examinations were unremarkable. Abdominal examination revealed an 11×4 cm mass in the right lower quadrant. It was firm in consistency but non-fluctuant. It was non-tender, non-pulsatile, and there was no cough impulse. There was very mild erythema over the area but no skin breaks.
Blood tests were significant for a raised white blood cell count (WCC) of 29.3×109/l, neutrophils 27.1×109/l, and C reactive protein (CRP) 222 mg/l. His electrolytes and creatinine were within the normal range. Liver function tests showed alkaline phosphatase (ALP) 272 U/l and α-glutamyl transferase (GGT) 116 U/l, with the rest of the results, including bilirubin, within normal limits. Chest radiograph was unremarkable. The abdominal film showed dilated small bowel and no large bowel could be seen. A computed tomography (CT) scan was requested as the suspicion was that this was not a simple abscess and there was a possibility of an intra-abdominal pathology. The CT showed a thick walled gallbladder with multiple calculi and air present (figs 1 and and2).2). There was also an extensive air and fluid collection in the layers of the abdominal wall and subcutaneous fat which arose from a perforation of the gallbladder. There was no free intra-abdominal fluid.
The differential in this patient with abdominal wall mass could include the following:
The patient was started on intravenous cefuroxime, metronidazole and gentamicin. Due to his multiple medical comorbidities, and after discussion with the patient and his family, it was agreed he would not be a surgical candidate but he was to continue full active treatment. CT guided percutaneous cholecystostomy (fig 3) was requested on the day of admission but was delayed until the following day due to logistical issues.
Despite the radiological intervention and antibiotics, the patient progressively deteriorated. Hospice input was received and the patient died peacefully 5 days after admission.
Gallstones are common with a prevalence of 10% in the USA and Western Europe. Most gallstones are asymptomatic and for those patients who develop symptoms, biliary colic is the most common presentation. More serious manifestations such as perforation, empyema, gangrenous cholecystitis and ascending cholangitis are rare. It has been estimated that for patients with gallstones, the risk of a serious complication as mentioned above is around 1% per year.1
Gallbladder perforation can be into the peritoneum or can cause a fistula to form with structures like the bowel or anterior abdominal wall. Nowadays it is rare to see a gallbladder perforation with a fistula to the anterior abdominal wall leading to a cholecystocutaneous fistula.2,3 Previous to the advent of routine abdominal surgery this was not such an uncommon appearance with more than 100 cases recorded in the literature in 1890.4 In the last 50 years, however, there have been only 20 cases recorded.5–8 This decrease may be attributed to the early diagnosis of gallstone disease, the use of broad spectrum antibiotics, and early surgical intervention.9
In the case presented here, a CT scan was used to make the diagnosis of gallbladder perforation. As the patient was not a candidate for surgery, and despite radiological and medical interventions, his condition progressively declined and he passed away 5 days after admission. Although a CT scan was used to diagnose the condition in this case, the literature suggests ultrasonography should be the initial imaging modality of choice for suspected gallbladder pathology.10
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.