A 79-year-old British Caucasian man with a known history of diabetes mellitus was admitted with severe right upper abdominal pain of one week's duration, which worsened on the day of admission and was associated with nausea and vomiting.
On physical examination our patient was apyrexial and hemodynamically stable. An abdominal examination revealed marked tenderness in his right upper quadrant. Laboratory investigations on admission showed a WCC 23.7 × 109/L, CRP 148 mg/L, alkaline phosphatase 54 IU/L, alanine aminotransferase 31 IU/L, bilirubin 12 mmol/L, amylase <30 IU/L and oxygen saturation on air of 95%.
He was treated for presumed acute cholecystitis and was started on co-amoxiclav, 1.2 g taken intravenously three times a day.
The day after his admission, an abdominal ultrasound scan revealed a gallbladder-shaped echogenic viscous fluid present in his gallbladder fossa with posterior acoustic shadowing. An unenhanced computed tomography (CT) scan of his abdomen taken on the same day showed his gallbladder to be slightly distended, with a few small calcific stones. However, the wall of the gallbladder did not appear thickened. No intra-hepatic or extra-hepatic duct dilatation was seen. There was a small rim of fluid anterior to the surface of the right lobe of his liver, between his gallbladder and duodenum, which was suggestive of acute cholecystitis.
Our patient responded well to the intravenous antibiotics, and after four days his blood counts had returned to normal (WCC 7.1 × 109/L; neutrophils 5.05 × 109/L). He was discharged home after five days, with a prescription for oral co-amoxyclav for five more days. An elective laparoscopic cholecystectomy was performed six weeks after discharge, by which time our patient had no abdominal pain and was otherwise well. Pre-operative blood test results were normal.
At the laparoscopy, the fundus of his gallbladder was found to be gangrenous and covered by adherent omentum. The omental adhesions were gently freed revealing an entirely gangrenous gallbladder, which was thick, black and distended. Forty milliliters of dark hemorrhagic fluid were aspirated to aid manipulation. The whole gallbladder was gangrenous up to the cystic duct (Figures and ). The Calot's triangle was dissected, and after division of the cystic duct and artery, clips were applied to the viable duct and artery. The procedure was completed uneventfully and a 14F drain left in the gallbladder fossa.
Our patient was well post-operatively and kept on antibiotics for five days. He was discharged uneventfully on the sixth day after the operation.