Haemorrhagic cholecystitis in a newly anticoagulated patient

Abstract

A 74-year-old man undergoing rehabilitation after pneumonia developed right upper quadrant abdominal pain. Five days earlier he had been commenced on apixaban for a new diagnosis of atrial fibrillation. Ultrasound and CT scans revealed an acalculous grossly thickened gallbladder, with high attenuation non-echogenic material both within and surrounding the structure. Active contrast extravasation was seen at the neck. On laparotomy, a perforated internally bleeding gallbladder containing a single calculus was found, with significant free blood within the abdomen. After cholecystectomy, the patient recovered slowly in hospital before nursing home placement.

Hemorrhagic Cholecystitis: An Uncommon Disease Resulting in Hemorrhagic Shock

“…Most of these discuss hemorrhagic cholecystitis in patients with uremia, coagulopathy, diabetes, and patients on anticoagulation. [1][2][3] Our patient shared these comorbidities, which likely put him at increased risk.…”

“…When left untreated in susceptible patients, transmural inflammation progresses to mucosal infarction, necrosis, and eventual vascular insult with resultant hemorrhage that is distinct from other forms of gallbladder necrosis secondary to cholecystitis. [1][2][3][4] Presenting symptoms vary, ranging from vague abdominal pain to catastrophic bleeding. 1 Patients who develop hemorrhagic cholecystitis are typically sicker at baseline because of their multiple comorbidities, which further complicates its presentation and diagnosis.…”

A case of haemorrhagic cholecystitis with no risk factors

“…HC has many possible causes, including trauma, neoplasms, aneurysmal rupture, portal hypertension, coagulopathy or anticoagulation therapy. It is possible that the documented proliferating prescription of these agents may increase the incidence of this entity in the future [ 3 ].…”

Acute hemorrhagic cholecystitis with gallbladder rupture and massive intra-abdominal hemorrhag

“…This is similar for other cases where patients were taking anticoagulants and presented with hemorrhagic cholecystitis. 4,[9][10][11] The patient later presented with substernal and subxiphoid pain that was worked up extensively given his cardiac history. This was likely related to early onset of acute on chronic cholecystitis, which was delayed in diagnosing.…”

“…7 Overall, the present case appears to have only been described in four other cases, to our knowledge. 4,[9][10][11] Although the diagnosis is rare, given this patient's complicated history and risk of bleeding, acute hemorrhagic cholecystitis with gallbladder rupture should remain in the differential diagnosis of patient management.…”