An atypical presentation of intrahepatic perforated cholecystitis: a modern indication to open cholecystectomy. Report of a case

Abstract

Background: Intrahepatic gallbladder perforation with chronic liver abscess formation was anecdotically reported in the literature. The aim of this work is to report a case of intrahepatic gallbladder perforation and its atypical clinical presentation.

Case presentation: A 62-year-old male patient came to our observation; his medical history showed intermittent fever up to 39-40°C of about 2 weeks and anorexia, with an overall weight loss of about 12 Kg. Physical examination of the abdomen was negative. An ultrasound of the liver and an abdominal CT angiogram detected a disomogeneous hypoechoic-hypodense area in the 5th segment of the liver. Differential diagnosis between hepatic abscess or gallbladder cancer remained open. A surgical exploration was planned. After laparoscopic exploration, a conversion to open procedure with an atypical resection of the 5th hepatic segment was performed. Histologic examination of the specimen showed an intrahepatic chronic perforation of the gallbladder with intrahepatic abscess.

Conclusion: To the best of our knowledge, 18 cases have been reported in the literature as a Niemeier type I perforation. Clinical presentation, even in its extreme rarity, is more often acute. Differential diagnosis between gallbladder cancer versus liver abscess remains controversial. Open approach is mandatory in such cases.

Figure 1

Preoperative Diagnostic. (A) Preop.-CT scan. A hypodense pseudocystic mass on the 5th liver segment, mimicking abscessed gallbladder cancer (bile stones are recognizable on the hilar part of the tumor). (B) MRI scan. Bubbles of free air inside the “tumour”.

Figure 2

Intraoperative finding: Intrahepatic perforation of the gallbladder. Due to strong hilar adhesions and structure visualization difficulties in laparoscopic view (A), a conversion to “open” approach was decided (B).

Figure 3

Specimen examination. A) A typical partial resection of the 5th Segment en-bloc with the gallbladder. Intrahepatic position of the gallbladder. B) Macroscopic details of the pathologic specimen: intrahepatic position of the gallbladder. C) Microscopic detail of the specimen (Zoom 10 X): chronic inflammatory cells (giant plurinucleated cells) mixed with hepatic regeneration nodes in the context of a granuloma under the gallbladder bed, effect of intrahepatic perforation. (Courtesy of Dr. Loredana Villari. Pathology Institute. Vittorio-Emanuele Hospital. Catania.).