Dropped Gallstones Causing a Perihepatic Abscess and Empyema

Abstract

Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy is a well-known occurrence; however, the consequences of spillage of gallstones in the peritoneum and particularly intrathoracic complications are less defined. We describe the delayed development of a perihepatic abscess and empyema in a patient five years following laparoscopic cholecystectomy secondary to dropped gallstones. A 53-year-old man with medical history significant for a laparoscopic cholecystectomy five years prior to acute cholecystitis presented with purulent cough, hemoptysis, night sweats, and right-upper quadrant (RUQ) pain. Computed tomography (CT) scan revealed 5.4 cm right-sided subpulmonic and 5.9 cm perihepatic fluid collections with an 8 mm focal radiopaque density within the perihepatic fluid collection. Open intra-abdominal exploration resulted in retrieval of a 1 cm intraperitoneal gallstone. Laparoscopic cholecystectomy is a common surgical operation during which gallstone spillage can occur, causing both intra-abdominal and intrathoracic complications, presenting even years after surgery. This necessitates an attempt to retrieve all free intra-abdominal gallstones during the initial operation.

“Target sign” from dropped gallstones after laparoscopic cholecystectomy

“…Perforation of the gallbladder during laparoscopic cholecystectomy has resulted in a reported incidence of dropped gallstones occurring in nearly 30% of patients [1] , [2] , [3] , [4] , [5] , [6] , [7] , [8] . A majority of dropped gallstones are retrieved intraoperatively; however, stones may become fragmented, inaccessible, or overlooked with a reported incidence of unretrieved stones in 2.4% of laparoscopic cholecystectomies [12 , 16] . Initially, dropped stones were considered harmless, but abscess and fistula formation are now well recognized complications of retained stones [1] .…”

“…Typically, spilled gallstones remain clinically silent and are considered harmless [1 , 2] . However, they may result in complications such as localized or systemic infection, fibrosis, adhesions, fistulization, or abscess formation [1] , [2] , [3] , [4] , [5] , [6] , [7] , [8] , [9] , [10] , [11] , [12] , [13] , [14] . The non-specific clinical symptoms of abdominal pain and fever along with variable time in presentation may result in delayed diagnosis [1 , 2 , 6] .…”

Review of imaging in post-laparoscopy cholecystectomy complications

“…Although dropped gallstones in the peritoneal and extraperitoneal cavity are usually asymptomatic, they may lead to abscess formation with an estimated incidence of approximately 0.3%. [ 53 ] Common locations of the abscess are abdominal wall, subhepatic, or retroperitoneum inferior to the subhepatic space. [ 53 ] On imaging, dropped gallstones are seen as hyperdense structures with or without surrounding abscess or inflammation [ Figure 20 ].…”

“…[ 53 ] Common locations of the abscess are abdominal wall, subhepatic, or retroperitoneum inferior to the subhepatic space. [ 53 ] On imaging, dropped gallstones are seen as hyperdense structures with or without surrounding abscess or inflammation [ Figure 20 ]. Dropped gallstones can present with abscess, empyema,[ 54 55 56 ] broncholith,[ 57 ] expectoration of stones,[ 58 59 ] ileus, intestinal obstruction, and incarcerated hernia.…”

A complicated abscess from a dropped gallstone

“…Between 1991 and 2015, there were little over 250 reported complications of spilled gallstones [2]. The most common complication is intra-abdominal abscesses while rare complications include intra-abdominal abscesses associated with empyema as well as intraluminal bowel erosion leading to mechanical obstruction [3,4]. We report a rare broncho-pleuro-cutaneous fistula caused by a dropped gallstone.…”