Skip to content PERICHOLECYSTIC ABSCESS PRESENTING AS PANCREATIC HEAD MASS Reema Agarwal1, jad Tabbara, Keniesha Thompson, M.D., 1SSM SLU Hospital, MO, SAINT LOUIS Case Presentation: We present a 42-year-old Caucasian female patient who presented with [shmabstracts.org]

METHOD: Data were retrospectively collected from clinical case notes and a literature review is presented. [ncbi.nlm.nih.gov]

Omental inflammation surrounding the GB was present in 5 cases at surgery. [em-consulte.com]

We herein present our experience of 32 cases of gallbladder perforation that presented to our hospital from January 2012 to November 2014. [synapse.koreamed.org]

• Fever

  Nausea, vomiting, abdominal pain and fever are characteristic. Fever should typically be low grade and last 1 week [ 1 ]. Gallbladder infarction is rare and reported at 1.1% [ 2 ]. [intjem.biomedcentral.com]

  Grande-Pérez, Jaqueline de Jesus Pereira, Fellippo Ramos Published in Revista espanola de enfermedades digestivas… 2009 A 75-year-old male patient with recurrent biliary colics attends the emergency service because of right upper-quadrant abdominal pain and fever [semanticscholar.org]

  Clinical History 90-year-old man with dementia presenting with abdominal pain and fever. Physical examination showed non-specific findings. Lab work-up revealed elevated WBC count and inflammatory markers. [eurorad.org]

  No fever of leukocytosis. [aast.org]

  Expect fever to resolve in 24 hours and diarrhea within 4-5 days [NEJM 346: 334, 2002]. [openanesthesia.org]

• Swelling

  At the operation the serosal layer was extremely swelling and a large amount of pus was discharged by the incision. A simple cholecystectomy was performed. [jstage.jst.go.jp]

  […] abscess Fever; perineal pain; diffuse swelling; pain with defecation; palpable fluctuant area on digital examination Endorectal ultrasound localization; CT may localize collection but MRI preferable Drainage of localized pus Culture of abscess positive [aast.org]

  A tear (perforation) in your gallbladder may result from gallbladder swelling, infection or death of tissue. Prevention You can reduce your risk of cholecystitis by taking the following steps to prevent gallstones: Lose weight slowly. [mayoclinic.org]

  Acute cholecystitis is swelling (inflammation) of the gallbladder. It is a potentially serious condition that usually needs to be treated in hospital. [nhsinform.scot]

• Malaise

  Fever and malaise for 3 days. Patient Data Age: 77 Gender: Male Loading images... Axial C+ portal venous phase Low-attenuation lesion in the liver adjacent to the gallbladder with subtle peripheral enhancement. Loading images... [radiopaedia.org]

  On the other hand patients may also show weakness, malaise and a palpable right upper quadrant mass, mimicking a malignacy. [wjes.biomedcentral.com]

  […] prolonged (> 6 hours) than in biliary colic Postprandial Radiation to the right scapula (due to referred pain from phrenic nerve irritation) Positive Murphy sign: sudden pausing during inspiration upon deep palpation of the RUQ due to pain Guarding Fever, malaise [www-amboss-com.db.rsu.lv]

• Pallor

  There was no pallor, icterus or cyanosis. The findings of the cardio-respiratory and nervous system examination were within normal limits. [ijpmonline.org]

  食道損傷 esophageal perforation食道穿孔 esophageal varices食道静脈瘤 esophagitis食道炎 esophagography食道造影 excretory duct導管 exocrine gland外分泌腺 external biliary fistula外胆汁瘻 extracorporeal shock wave lithotripsy (ESWL)体外衝撃波結石破砕術（ESWL） extrahepatic bile duct肝外胆管 f facial pallor [tokyo-med.ac.jp]

• Fatigue

  Nonspecific symptoms include diarrhea, upset stomach, fatigue, altered mental status, and jaundice. Hemorrhagic AAC has been reported in patients with end-stage renal disease (ESRD). [rarediseases.org]

• Pleural Effusion

  Liver abscesses may be associated with amorphous gas collection in the liver (as many as 20 percent of cases) or basilar atelectasis, right hemidiaphragm elevation, and right pleural effusion (about 50 percent of cases). [aafp.org]

  Respiratory signs of pleural effusion and basal collapse are found in 10-20% of patients as observed in the present case. [1], [3], [5] Blood/ plasma amylase levels are elevated which confirms the diagnosis. [ijpmonline.org]

  Pleural Space Infection AAST Grade Description Clincal Criteria Imaging Criteria Operative Criteria Pathologic Criteria I Retained hemothorax or pleural effusion with positive pleural fluid cultures Leukocytosis, fever, chest pain Pleural fluid consistent [aast.org]

  Effusion (CXR) 33% Extraluminal air or air-fluid level (KUB) 13% Basilar atelectasis (CXR) 12% Palpable abdominal mass (exam) 7% Mechanical bowel obstruction (KUB) 4% Surg Clin North Am 74: 693, 1994 Treatment is drainage, empiric antibiotic therapy [openanesthesia.org]

  […] pancreatectomy膵切除術 pancreatic calcification膵石灰化 pancreatic cyst (cyst of pancreas)膵嚢胞 pancreatic duct cell carcinoma膵管癌 pancreatic functioning diagnostant (PFD) test (BT-PABA test, bentiromide test)PFD試験＝BT-PABA試験、ベンチロミド試験 pancreatic juice膵液 pancreatic pleural [tokyo-med.ac.jp]

• Abdominal Pain

  Esophageal Perforation AAST Grade Description Clinical Criteria Imaging and/or endoscopic criteria Operative Criteria Pathologic criteria I Mucosal tear Dysphagia; chest pain, upper abdominal pain or back pain; breathing problems No abnormality or possible [aast.org]

  A 75-year-old male was admitted to the hospital because of a sudden onset of right upper abdominal pain after a lunch. Abdominal CT scan findings of the gallbladder performed preoperatively had a strange shape which seemed like a record disk. [jstage.jst.go.jp]

  pain and fever for two days. [semanticscholar.org]

  […] presentation An 80 year old male patient was admitted to our hospital with abdominal pain for 3 to 4 days. [openaccessjournals.com]

• Upper Abdominal Pain

  A 75-year-old male was admitted to the hospital because of a sudden onset of right upper abdominal pain after a lunch. Abdominal CT scan findings of the gallbladder performed preoperatively had a strange shape which seemed like a record disk. [jstage.jst.go.jp]

  CASE SUMMARY A 78-year-old man with a past medical history of rectal cancer presented to the emergency department with upper abdominal pain, increasing confusion, and urinary incontinence. A physical exam was unremarkable with temperature of 97.7 F. [appliedradiology.com]

  abdominal pain (most common RUQ) that can radiate to right shoulder/scapula area Initially colicky pain, then constant, severe pain > 6 hrs duration Nausea/vomiting, fever Acalculous cholecystitis may present similiarly, but often present w/ fever and [fprmed.com]

• Right Upper Quadrant Tenderness

  Right upper quadrant pain, palpable right upper quadrant tenderness or high fever may indicate an acute onset. On the other hand patients may also show weakness, malaise and a palpable right upper quadrant mass, mimicking a malignacy. [wjes.biomedcentral.com]

  The abdomen revealed right upper quadrant tenderness with Murphy’s sign and muscular defense of the upper abdomen. [bmcnephrol.biomedcentral.com]

• Tachycardia

  Examination revealed a markedly obese, dehydrated patient with tachycardia and tachypnoea. A large, tender and non-mobile mass was palpable in the right lumbar and iliac regions of the abdomen, extending from the right flank up to the umbilicus. [bioline.org.br]

  On examination the patient may look septic with systemic signs of infection (pyrexia and tachycardia) and local RUQ peritonism. Murphy's sign is usually positive. [gponline.com]

  Hernia visible on CT Abdominal wall defect present with abdominal contents lodged in defect; healthy appearing viscera N/A III Incarcerated with bowel ischemic but viable Local tenderness with non-reducible palpable hernia; may be associated with fever, tachycardia [aast.org]

  […] ulcer)吻合部潰瘍 subacute bacterial endocarditis 亜急性細菌性心内膜炎 subacute hepatic necrosis亜急性肝壊死 submucosal layer粘膜下層 superficial gastritis表層性胃炎 superior mesenteric artery syndrome (arteriomesenteric occlusion of duodenum)上腸間膜動脈症候群 suppository坐薬 swallowing嚥下運動 t tachycardia [tokyo-med.ac.jp]

  Fever and tachycardia are commonly absent in acute cholecystitis; maintain a high index of clinical suspicion! [www-amboss-com.db.rsu.lv]

• Murphy's Sign

  […] attention to clinical status important when assessing for sonographic Murphy’s sign Rubens DJ. [slideshare.net]

  Cholelithiasis, sonographic Murphy sign, and GB wall thickening • CT findings Distended GB (measuring > 5 cm in short axis) GB wall thickening (> 3 mm) with mural and mucosal hyperenhancement and pericholecystic fat stranding Calcified gallstones may [clinicalgate.com]

  The patient experiences pain when palpated on the right hypochondrium, with Murphy’s sign and a temperature of 38 oC. [semanticscholar.org]

  Examples include GB thickening, calculi in the GB, a positive ultrasonographic Murphy sign, and pericholecystic fluid. The sonographic Murphy sign is negative in as many as 70% of patients with AC. [emedicine.medscape.com]

  May progress to complicated cholecystitis rapidly and w/o warning Physical Exam/Signs General, Vitals: fever, guarded, positive Murphy sign, jaundice (15%) Murphy's sign had highest specificity (79-96%) but low sensitivity (20-87.5%) Absence of physical [fprmed.com]

• Biliary Colic

  colics attends the emergency service because of right upper-quadrant abdominal pain and fever for two days. [semanticscholar.org]

  Biliary colic Biliary colic occurs when a gallstone impacts in the neck of the gallbladder obstructing the cystic duct. The pain resolves spontaneously as the stone falls back into the gallbladder or passes into the common bile duct (CBD). [gponline.com]

  […] tract cancers. 12 Biliary Colic The pain of biliary colic occurs when the gallbladder contracts, forcing a stone and/or sludge against the gallbladder neck or opening of the cystic duct. [ahcmedia.com]

  Pyelonephritis Presentation History Right upper quadrant (RUQ) pain History of similar, self-limited pain (biliary colic) Nausea/Vomiting Radiation of pain to the tip of the right scapula (referred pain) Physical Examination RUQ/epigastric tenderness [coreem.net]

  colic.[1] Biliary colic is abdominal pain in the right upper quadrant or epigastric region. [en.wikipedia.org]

• Liver Mass

  […] and biliary (MRCP); MR of kidney and adrenal glands; prostate MR; MR of focal liver masses; MR of pancreas; MR enterography; gadolinium contrast agent selection and optimal use for body MRI; MR angiography and venography of abdomen and pelvis; functional [books.google.com]

  Liver abscess secondary to intrahepatic perforation of the gallbladder, presenting as a liver mass. Am J Gastroenterol. 1996;91:1644–6. Ceylan H, Sirikci A, Ozokutan BH, Bayram M, Sivasli E. [tropicalgastro.com]

  […] is significant for carcinoma "Constrained Stone Sign" -GB Wall thickened and hypoechoic -GB poorly distinguished from the liver GB carcinoma metastasize to: -Cystic duct -Adjacent bile duct -Liver -When lesions extend into liver masses may lie in contact [quizlet.com]

  Bakalakos EA, Melvin WS, Kirkpatrick R: Liver abscess secondary to intrahepatic perforation of the gall bladder, presenting as a Liver mass. Am J Gastroenterol 1996;91:1644-1646. 13. [jemds.com]

• Gallbladder Tenderness

  The gallbladder may be encased in inflammatory mass Toxic patient RUQ pain and tenderness Swinging pyrexia Tender RUQ mass Rarely responds to conservative measures. [gponline.com]

• Irritability

  […] bowel syndrome (irritable colon syndrome)過敏性腸症候群 irritable colon刺激性結腸 j jaundice (icterus)黄疸 jejunum空腸 k ketone bodyケトン体 ketone groupケトン基 l lamina muscularis mucosae粘膜筋板 laparoscope (peritoneoscope)腹腔鏡 laparoscopic cholecystectomy (lapcholy)腹腔鏡下胆嚢摘出術 [tokyo-med.ac.jp]

  In this case, the overall outcome is dismal because gallbladder cancer has a predilection for seeding and spreading to the adjoining anatomical structures.[10][11] Complications Necrotizing fasciitis Skin irritation Malignant changes Pearls and Other [statpearls.com]

  The physical examination confirmed tenderness of the right upper quadrant with initial signs of peritoneal irritation. [wjes.biomedcentral.com]

  Biliary events and an increased risk of new onset irritable bowel syndrome: a population-based cohort study.. [www-amboss-com.db.rsu.lv]

  This results in mucosal damage by bile with a consequential chemical irritation, inflammatory infiltration and oedema of the gallbladder wall. Possible outcomes are summarised in the box. [gponline.com]

The definitive diagnosis can only be made on histological and bacteriological workup. [acgcasereports.gi.org]

[…] other abdominal structures (can identify an alternative diagnosis), provides preoperative information such as gallbladder size, stone size, gallbladder wall status and the presence of biliary dilatation 19 The addition of a HIDA scan in the diagnostic workup [imagingpathways.health.wa.gov.au]

Tests to rule out differential diagnoses: See “Diagnostic workup of acute abdominal pain.” Imaging [9][10] RUQ transabdominal ultrasound See also “Biliary point-of-care ultrasound.” [www-amboss-com.db.rsu.lv]

If this is the case, laboratory tests and an ultrasound should be obtained as part of the initial workup. For patients who are ultimately diagnosed with biliary colic, outpatient surgical follow-up should be arranged. [ahcmedia.com]

• Pneumoperitoneum

  Pneumoperitoneum often is caused by perforation of the hollow organs. [aafp.org]

  Emphysematous cholecystitis occurring in association with a pneumoperitoneum is relatively rare [ 6, 7 ]. [bmcnephrol.biomedcentral.com]

  Large gallstone impacted on duodenal bulb (straight arrow in A) and pneumoperitoneum (open arrow in A and B) can be identified. [ijri.org]

  Complications that might follow GB perforation are pneumoperitoneum, bile leakage, liver GB fossa or intraperitoneal abscess formation and small bowel obstruction. [14] USG, CECT and MRI are the important imaging modalities for preoperative diagnosis [jemds.com]

  However, the plain radiograph also shows features of a pneumoperitoneum. At laparotomy, a perforated cecal carcinoma was found. There were no findings of acute cholecystitis. [emedicine.medscape.com]

• Atelectasis

  Liver abscesses may be associated with amorphous gas collection in the liver (as many as 20 percent of cases) or basilar atelectasis, right hemidiaphragm elevation, and right pleural effusion (about 50 percent of cases). [aafp.org]

  Clin North Am 74: 693, 1994] Utility (or lack thereof) of Clinical Exam in Intra-Abdominal Abscess Clinical Finding Frequency Localized abdominal tenderness (exam) 36% Pleural Effusion (CXR) 33% Extraluminal air or air-fluid level (KUB) 13% Basilar atelectasis [openanesthesia.org]

  The proper management of fluid and electrolyte replacement, respiratory management to prevent atelectasis and pneumonia, and monitoring for possible cardiac complications are necessary to minimize the risk of systemic complications in the perioperative [mdpi.com]

• Right Pleural Effusion

  Liver abscesses may be associated with amorphous gas collection in the liver (as many as 20 percent of cases) or basilar atelectasis, right hemidiaphragm elevation, and right pleural effusion (about 50 percent of cases). [aafp.org]

• Neutrophilia

  Laboratory studies revealed leukocytosis with neutrophilia (15,000 leukocytes/mm3, 80% neutrophils) with hepatic enzymes and normal pancreatic amylase. An initial ultrasound exam was performed, which showed evidence of… CONTINUE READING [semanticscholar.org]

  Laboratory studies revealed leukocytosis with neutrophilia (15,000 leukocytes/mm3, 80% neutrophils) with hepatic enzymes and normal pancreatic amylase. [scielo.isciii.es]

• Clostridium Perfringens

  Coli /Myonecrosis- Safioleas et al. (2007) [ 26 ] 10 70 M Heart disease Hyperlipidemia Yes Multiple small GB stones Yes (Ce)/Yes Bi/C: Clostridium perfringens-/ - Shresth et al. (2007) [ 27 ] 11 68 M Hypertension CAD Type 1 − Yes (Ce)/Yes B/C: Clostridium [bmcnephrol.biomedcentral.com]

  Emphysematous Cholecystitis General considerations Acute infection of gallbladder caused by gas-forming organism In about 1/3 = clostridium perfringens Also E. [learningradiology.com]

  It is most common in older men with diabetes and has a 15 percent mortality rate. 1 It is caused by proliferation of gas-forming organisms (e.g., Clostridium perfringens, Escherichia coli ) after vascular compromise of the gallbladder. [aafp.org]

  Gas in the gallbladder wall formed by Clostridium perfringens, Escherichia coli and anaerobic streptococci. [gponline.com]

• Pleural Effusion

  Liver abscesses may be associated with amorphous gas collection in the liver (as many as 20 percent of cases) or basilar atelectasis, right hemidiaphragm elevation, and right pleural effusion (about 50 percent of cases). [aafp.org]

  Respiratory signs of pleural effusion and basal collapse are found in 10-20% of patients as observed in the present case. [1], [3], [5] Blood/ plasma amylase levels are elevated which confirms the diagnosis. [ijpmonline.org]

  Pleural Space Infection AAST Grade Description Clincal Criteria Imaging Criteria Operative Criteria Pathologic Criteria I Retained hemothorax or pleural effusion with positive pleural fluid cultures Leukocytosis, fever, chest pain Pleural fluid consistent [aast.org]

  Effusion (CXR) 33% Extraluminal air or air-fluid level (KUB) 13% Basilar atelectasis (CXR) 12% Palpable abdominal mass (exam) 7% Mechanical bowel obstruction (KUB) 4% Surg Clin North Am 74: 693, 1994 Treatment is drainage, empiric antibiotic therapy [openanesthesia.org]

  […] pancreatectomy膵切除術 pancreatic calcification膵石灰化 pancreatic cyst (cyst of pancreas)膵嚢胞 pancreatic duct cell carcinoma膵管癌 pancreatic functioning diagnostant (PFD) test (BT-PABA test, bentiromide test)PFD試験＝BT-PABA試験、ベンチロミド試験 pancreatic juice膵液 pancreatic pleural [tokyo-med.ac.jp]

• Leukocytosis

  No fever of leukocytosis. [aast.org]

  Laboratory studies revealed leukocytosis with neutrophilia (15,000 leukocytes/mm3, 80% neutrophils) with hepatic enzymes and normal pancreatic amylase. An initial ultrasound exam was performed, which showed evidence of… CONTINUE READING [semanticscholar.org]

  Blood tests showing elevated levels of white blood cells (leukocytosis), elevated C-reactive protein, may be signs of infection and inflammation. [rarediseases.org]

  Laboratory studies revealed leukocytosis with neutrophilia (15,000 leukocytes/mm3, 80% neutrophils) with hepatic enzymes and normal pancreatic amylase. [scielo.isciii.es]

  /or the lumen May spread to pericholecystic tissue Rarely, gas may escape into the bile ducts This is rare since cystic duct is usually occluded in cholecystitis Clinical findings As with cholecystitis, right upper quadrant (RUQ) pain and tenderness Leukocytosis [learningradiology.com]

Application of laparoscopic appendectomy to treatment of periappendiceal abscess 腹腔镜治疗阑尾周围脓肿的应用 2. [dictall.com]

Treatment To treat a pericholecystic abscess, early diagnosis and intervention is the key to successful outcomes. The initial treatment for gallbladder perforation may be percutaneous cholecystostomy. [verywellhealth.com]

Prognosis Gallbladder perforation with pericholecystic abscess is a rare disorder. It is considered a life-threatening, emergency complication of acute cholecystitis. [verywellhealth.com]

• The etiology of emphysematous cholecystitis is controversial, but it is considered to be due to ischemia of the gallbladder from primary vascular compromise, with secondary proliferation of gas-producing bacteria. 13. limited• Note:• Wall thickening [slideshare.net]

[…] sign • Radiography : Insensitive for detection of ectopic gas • MR : Intraluminal and intramural gas appear as signal voids on all pulse sequences PATHOLOGY • Infection of GB with gas-forming organisms such as Clostridium welchii and Escherichia coli • Etiology [radiologykey.com]

[…] of all cases of acute cholecystitis Occurs more often in men As opposed to gallbladder disease in general which occurs more often in women Mostly are elderly patients (>60) with diabetes Vascular compromise of the cystic artery may play a role in the etiology [learningradiology.com]

Focal sclerosing cholangitis -Primary liver tumor -Tumor of duct Complications of Gallstones -Porcelain GB -Milk of Calcium Bile -Cholecystitis -95% associated with gallstones -5 times more common in females -11-33% carcinomas have calcification in wall Etiology [quizlet.com]

[…] wall perforations covered up by surrounding tissue forming abscesses Biliary fistula: duodenal-gallbladder fistula formation, usually d/t erosion of wall into duodenum by large stone; stone can travel to ileocecal valve and cause SBO (gallstone ileus) Etiology [fprmed.com]

Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines.. [www-amboss-com.db.rsu.lv]

Epidemiology of gallbladder disease: Cholelithiasis and cancer. Gut Liver 2012;6:172-87. 2. Unisa S, Jagannath P, Dhir V, Khandelwal C, Sarangi L, Roy TK. [ijri.org]

Incidence/Prevalence No large epidemiological study to date, but estimated 10% US pop has gallstones Up to 12% develop acute cholecystitis (most frequent complication of gallstones) after 5-7 yrs Up to 6% develop severe acute cholecystitis Prevalence [fprmed.com]

Epidemiology Due to the rarity of the condition, the available information are limited. The affected patients are usually older females. When questioned, patients may mention previous episodes of right upper quadrant pain. [statpearls.com]

"Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines". Journal of Hepato-Biliary-Pancreatic Surgery. 14 (1): 15–26. doi:10.1007/s00534-006-1152-y. ISSN 0944-1166. PMC 2784509. [en.wikipedia.org]

[…] of the biliary outflow by a gallstone is thought to play a significant role in the pathophysiology of the development of this condition. [statpearls.com]

This complication occurs in 2-10% of cases of acute cholecystitis. (1) With the increase in cholecystectomies in modern surgical practice, gallbladder perforation is becoming rare with a reported incidence of 0.8%. (2) The pathophysiology leading to perforation [appliedradiology.com]

Pathophysiology Cystic duct obstruction is the proximate cause of cholecystitis Obstruction leads to gallbladder distension An inflammatory reaction occurs due to either mucosal ischemia from increased hydrostatic pressure or cytotoxic effects of bile [coreem.net]

Sleisenger & Fordtran's Gastrointestinal and liver disease pathophysiology, diagnosis, management (9 ed.). [S.l.]: MD Consult. p. 1065. ISBN 9781437727678. [en.wikipedia.org]

On the contrary, the indications for such intervention are always widening, as its risks become always smaller and the requirements for prevention higher. [books.google.ro]

Read more about preventing gallstones. [nhsinform.scot]

Prevention You can reduce your risk of cholecystitis by taking the following steps to prevent gallstones: Lose weight slowly. Rapid weight loss can increase the risk of gallstones. [mayoclinic.org]

Dr Sern Chin Lim Dr International Medical Universitry Malaysia Primary Prophylaxis to Prevent the Development of Hepatic Encephalopathy in Cirrhotic Patients with Acute Variceal Bleeding. [pubfacts.com]

Relapses occur in 25% of cases, but 75% of these will respond to the same antibiotic if repeated [Lancet ID 5: 549, 2005] Prevention of C.difficile Prevention is primarily by rational antibiotic use and possibly the use of probiotics (in one study, 1 [openanesthesia.org]