Late Hemorrhage Following Laparoscopic Cholecystectomy

Excruciating generalized abdominal pain with features suggestive of shock, at the end of the first or early second week after laparoscopic cholecystectomy (LC), is a frightening and formidable diagnostic predicament. This is because the early known complications like biliary leak or vascular injuries are unlikely diagnoses. Hemoperitoneum, is not usually considered, but instead more common occurrences like acute pancreatitis, choledocholithiasis, and sepsis are suspected. A delay in diagnosis and subsequent management of hemoperitoneum could have disastrous consequences.

Two patients presented with hemoperitoneum, in the second week after laparoscopic cholecystectomy. The first was because of a leak from a pseudoaneurysm of the right hepatic artery and the other was a bleed from a subcapsular liver hemangioma as a part of Osler Weber Rendu syndrome. Initially, a clinical assessment in both the patients was diagnostically inconclusive. Ultimately the diagnosis could be made, based on computed tomography angiography and visceral angiography. In the second patient, a positive family history and genetic testing were helpful. The first patient was successfully managed by intravascular embolization, while the second patient was successfully managed conservatively with intraperitoneal drains and conservative management of comorbidities.

The presentation is to generate awareness that hemorrhage could be a presentation, in the early second week, after LC. A common cause to be considered is a pseudo aneurysmal bleed. Secondary hemorrhage and other rare coincidental unassociated conditions could also be responsible for the hemorrhage. A high index of suspicion, and early and timely management are keys to a successful outcome.