A Case of Hemorrhagic Cholecystitis in a Patient on Apixaban After COVID-19 Infection

Abstract

BACKGROUND Hemorrhagic cholecystitis is a rare cause of abdominal pain, which can result from malignancy, bleeding, or trauma. The presentation, which includes right upper-quadrant pain, nausea, and vomiting, can overlap with other disease states, thereby rendering the diagnosis challenging. CASE REPORT We describe a patient taking apixaban wo had paroxysmal atrial fibrillation with history of joint pain on long-term steroids who developed hemorrhagic cholecystitis following an episode of pneumonia secondary to SARS-CoV-2 virus (COVID-19) infection. The hospital COVID-19 pneumonia protocol included the administration of steroids and symptomatic care. Following discharge, he presented to our hospital with a sudden onset of severe abdominal pain and distention accompanied by elevated liver enzymes and a low hemoglobin level of 78 g/L. Magnetic resonance cholangiopancreatography revealed a distended gallbladder and intraluminal layering, early subacute blood products, and increased wall thickness, which was thought to represent non-calcular hemorrhagic cholecystitis. Furthermore, a stable 18×16×20 mm cyst in the tail of the pancreas was also located posteriorly, with indentation to the splenic vein. The patient was managed conservatively, and the pain subsided on day 3 after admission. CONCLUSIONS Hemorrhagic cholecystitis is rarely reported with the use of the direct oral anticoagulants (DOACs). In our case the combination of a recent COVID-19 hospitalization, steroid use, and possible pancreatic cancer (CA 19-9 288.4 kU/L) may have contributed to such incidence in the setting of apixaban utilization; however, it is not possible to make definitive correlations. Investigating hemorrhagic cholecystitis in the setting of DOAC use in patients with multiple risk factors such as those that existed in our patient is imperative for proper diagnosis and management.

Figure 1.

Axial non-contrast CT scan of the abdomen shows distended gallbladder by intraluminal hyperdense material with average of 48 Hounsfield units. Increased wall thickness. No stones or masses seen.

Figure 2.

Axial T1- (A) and T1 FS- (B) weighted images from non-contrast MRI abdomen shows distended gall bladder by intraluminal hyperintense material (arrowed) and thickened hyperintense wall.

Figure 3.

Axial T2-weighted image from non-contrast MRI abdomen shows distended gall bladder by intraluminal mildly hyperintense material (arrowed) and thickened bright wall.

Figure 4.

CT scan of the abdomen showing pancreatic cyst (arrow).