Case Presentation:
Acute cholecystitis is a very common disease, suspected by the patient’s history and physical examination, confirmed by ultrasonographic imaging, and supported by lab findings suggestive of obstructive jaundice. Our patient had an atypical presentation of cholecystitis, secondary to her atypical anatomy.
We present a 61 year old Hispanic woman with past medical history of hyperlipidemia, migraine headaches and gastritis who presented with diffuse, pressure-like abdominal pain for 7 days, which was aggravated by movement, and mildly relieved by ibuprofen without any correlation to food. This was associated with nausea, vomiting and anorexia. On examination, she appeared septic with mild tenderness in the right upper quadrant of the abdomen with normal bowel sounds. She was found to have hyperbilirubinemia, elevated transaminases and elevated alkaline phosphatase with borderline leukocytosis. A CT scan of the abdomen was performed revealing a large hepatic sub-capsular fluid collection, along with fatty liver and mild scattered ascites and a decompressed gall bladder. She was treated with broad spectrum antibiotics and needle aspiration of the biloma. Despite drainage, her liver enzymes were persistently elevated, so an ERCP was performed. This revealed biliary stones in the common bile duct (CBD) and large stones at the insertion of the cystic duct into the CBD with leakage of contrast at the site that should be the gallbladder. A surgical consult was obtained and the patient underwent exploratory laparotomy exposing a contracted gallbladder within the hepatic capsule, and Mirizzi morphology inserting directly onto the common bile duct in the manner of a true Mirizzi syndrome. A distal cube-shaped stone in the fundus of the gallbladder contained sharp edges causing erosion of the fundus of the gallbladder, resulting in bile leakage within the hepatic capsule. The gallbladder was then surgically resected with common bile duct repair over a T-tube.
Discussion:
Conclusions: