Intrahepatic Rupture of Acute Cholecystitis Complicated by Septic Portal Thrombosis

Area of Science:

• Hepatobiliary Surgery
• Gastroenterology
• Interventional Endoscopy

Background:

• Gallbladder rupture is a rare but severe complication following interventions for choledocholithiasis, such as ERCP.
• Covered metal stents, while useful, can obstruct the cystic duct orifice, especially with low cystic duct junctions, potentially leading to cholecystitis.

Observation:

• A patient developed acute cholecystitis, gallbladder rupture, and a liver abscess after ERCP with a covered metal stent for common bile duct stones.
• The liver abscess, caused by Streptococcus anginosus, was managed with percutaneous drainage and antibiotics.
• Portal vein thrombosis was also identified and treated with anticoagulation.

Findings:

• Metal biliary stents can obstruct the cystic duct in over 33% of patients with a low cystic duct junction.
• Obstructed cystic ducts can lead to obstructive acute cholecystitis and subsequent gallbladder rupture and liver abscess formation.
• Streptococcus anginosus is a common pathogen in these complex hepatobiliary infections.

Implications:

• Careful selection of biliary stents is crucial to prevent post-ERCP complications.
• Prophylactic cholecystectomy may be considered in patients with a functioning gallbladder undergoing ERCP to mitigate risks.
• Prompt diagnosis, drainage, and antibiotic therapy are essential for managing gallbladder rupture and associated infections.