Perforated Hemorrhagic Cholecystitis After Coronavirus Disease 2019 (COVID-19) in a Patient Receiving Anticoagulant Therapy

Hemorrhagic cholecystitis (HC) is a rare but life-threatening condition. While anticoagulant therapy is a known risk factor, the coronavirus disease 2019 (COVID-19) has recently emerged as another trigger. We experienced a severe case of perforated HC complicated by hemoperitoneum in a patient presenting both risk factors. An 87-year-old male patient on apixaban therapy was admitted to a referral hospital seven days before COVID-19, where treatment with antiviral medication and steroids was initiated. Five days before transfer, the patient developed abdominal pain with elevated levels of inflammatory markers. On the day of presentation, the patient experienced sudden right upper abdominal pain and was transferred to our hospital following plain computed tomography (CT), which revealed gallbladder enlargement and suspected hemoperitoneum. Upon arrival, the patient exhibited diffuse abdominal tenderness. Contrast-enhanced CT revealed extravasation from the cystic artery and hematomas around the gallbladder, confirming the diagnosis of HC with hemoperitoneum. Emergency laparoscopic cholecystectomy was performed after administration of recombinant Factor Xa (used to reverse anticoagulation). Intraoperatively, hemorrhagic ascites were observed, with the gallbladder appearing tense, gangrenous, and perforated. A histopathological examination confirmed acute cholecystitis with necrosis and perforation. The postoperative course was uneventful, and apixaban therapy was restarted on postoperative day 1. The patient was discharged to a rehabilitation facility on postoperative day 13. Emergency laparoscopic cholecystectomy was lifesaving in this patient with HC and hemoperitoneum.