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Year : 2018  |  Volume : 6  |  Issue : 1  |  Page : 22-24

Simultaneous acute acalculous cholecystitis and acute appendicitis: A case report and literature review

1 Department of General Surgery, King Khalid Hospital, Hail, Saudi Arabia
2 Department of Surgery, King Khalid Hospital, Hail, Saudi Arabia
3 Department of Internal Medicine, King Khalid Hospital, Hail, Saudi Arabia

Date of Web Publication27-Feb-2018

Correspondence Address:
Dr. Alaa Mohamed Sedik
Department of General Surgery, King Khalid Hospital, Hail
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ssj.ssj_8_17

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While acute appendicitis and acute calculous cholecystitis are both common, acute acalculous cholecystitis (AAC) is traditionally rare and usually encountered in the elderly or critically ill patients. Here, we reported a case of simultaneous AAC and acute suppurative appendicitis occurring in a young female that was managed by open cholecystectomy and appendectomy at the same time.

Keywords: Acute cholecystitis, appendicitis, dual abdominal pathology

How to cite this article:
Sedik AM, Makhdoomi M, El Dakak A, El Houshy S. Simultaneous acute acalculous cholecystitis and acute appendicitis: A case report and literature review. Saudi Surg J 2018;6:22-4

How to cite this URL:
Sedik AM, Makhdoomi M, El Dakak A, El Houshy S. Simultaneous acute acalculous cholecystitis and acute appendicitis: A case report and literature review. Saudi Surg J [serial online] 2018 [cited 2018 Mar 23];6:22-4. Available from: http://www.saudisurgj.org/text.asp?2018/6/1/22/226232

  Introduction Top

Both acute appendicitis and acute calculous cholecystitis are among the most common diagnoses that general surgeons operate on. On the other hand, acute acalculous cholecystitis (AAC) is rare clinically. Few cases diagnosed with simultaneous acute appendicitis reported in the literature. It usually occurs in the elderly with extensive comorbidities or critically ill patients. AAC has a high mortality rate due to the difficulties in early diagnosis and high rate of complications such as empyema, gangrene, and perforation.

  Case Report Top

A 35-year-old Sudanese female known to have primary infertility and chronic iron deficiency anemia due to heavy periods was admitted through our emergency room with worsening upper right quadrant abdominal pain over 3 days before presentation together with low-grade fever for 1 day. She had nonbloody diarrhea and occasional vomiting over the last 2 weeks. No history of similar attacks. No history of jaundice, change of color of urine or stool color. No history of heartburn, fatty dyspepsia, or loss of weight.

Clinically, she looked ill, pale, febrile, with tachycardia of 120/min, and low blood pressure (BP) of 85/50 mmHg. SO2%94 on O2 mask, no jaundice. She was in pain. Chest examination showed bilateral crepitations; more on the right side. Mild bilateral lower limb edema was noted.

Abdominal examination showed diffuse tenderness all over but maximally over the right upper quadrant with positive Murphy's sign. No rigidity or rebound was noted. Bowel sounds were normal. Rectal examination was unremarkable. Initial blood works showed Hb of 6.2 gm%, white blood cell (WBC) 14,000/cmm, platelets were 100,000/cmm, international normalized ratio was 1.7, prothrombin time, partial thromboplastin time mildly elevated. The liver functions were elevated including total bilirubin of 44 μmol/L except low albumin of 18 g/L. Mildly elevated renal functions were noted. Serum amylase was 54 and serum lipase was 836. C-reactive protein was positive and erythrocyte sedimentation rate was 28. Arterial blood gases showed metabolic acidosis.

Immediate resuscitation was started in Intensive Care Unit with oxygen, intravenous fluids (IF) fluids, packed red blood cells, fresh frozen plasma, antibiotics,…etc., for stabilization and correction of coagulopathy state. Initial abdominal ultrasonography showed a picture of AAC with edema, thickening of the wall, and pericholecystic fluid around with no evidence of gallstones. The patient was seen by chest, medical and nephrology consultations.

She showed improvement over the first 36 h, with improvement of BP, subsidence of fever, and pain became less. Laboratory works showed correction of metabolic acidosis and a rise of Hb to 8.5 correction of disseminated intravascular coagulation. A contrast enhanced computerized scan of the abdomen, and magnetic resonance cholangiopancreatography of the biliary system [Figure 1] were arranged to confirm the diagnosis of AAC with moderate intraperitoneal fluid, right side.
Figure 1: (a) Magnetic resonance cholangiopancreatography image showed pericholecystic fluid around inflamed gall bladder without stone inside. (b) A computerized abdominal scan showing pericholecystic fluid around inflamed gallbladder with no stones inside. (c) Computerized scan of abdomen showing perihepatic free intraperitoneal fluid

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A picture of AAC is shown in (a and b). Mild free intraperitoneal fluid is shown in (c). Pleural effusion and basal consolidation. No other intra-abdominal pathology detected.

Unfortunately, she was deteriorated again. The pain worsened quickly, and she developed local rigidity, and rebound tenderness over the right upper quadrant and follow-up laboratory works showed a sharp rise of WBC to 54,000. The situation discussed, and patient consented and prepared for urgent surgery. Through a transverse upper right quadrant incision, the gall bladder found severely inflamed with gangrenous patches on the fundus. Culture swab was taken from the purulent intraperitoneal fluid. Inflamed appendix was found. Cholecystectomy and appendectomy were done. Saline wash was done and two intraperitoneal drains (sub-hepatic and pelvic) were left then the abdomen was closed.

Postoperatively, physiotherapy and incentive spirometry advised. She improved gradually and started oral fluids on the 2nd postoperative day. Diarrhea improved. Hepatitis profile and  Salmonella More Details serology came to be negative. Bile, stool, and intraperitoneal cultures were negative also. She tolerated oral feeding and was ambulating early. Her laboratory works were improved including WBC, albumin. Pathology report came to be consistent with AAC and acute suppurative appendicitis.

Over the 1st postoperative day, drains brought large amounts of 300 ml or more of clear serous transudate fluid when a sample was sent to the laboratory, then the amount decreased to 25 ml before removal and discharge on the 14th day in a good condition. Her skin clips removed.

She was seen for follow-up in surgery outpatient department (OPD) and was free of complications. She is followed up in the medical and gastroenterology and gynecology OPD.

  Discussion Top

AAC is a well-known but poorly understood clinical entity. Usually, it occurs in critically ill patients, especially those who are related to trauma, surgery, sepsis, total parenteral nutrition, etc.

Recent reports demonstrate increasing de novo presentation of AAC in the absence of acute illness[1] and even in young, otherwise healthy controls without any predisposing factors.[2]

The most common postulated etiologies of AAC are bile stasis resulting in a change in bile composition, sepsis, shock, and ischemia in critically ill patients.[3] It has previously been noted that a hyperbilirubinemia occurs in acute appendicitis.[4] It has been suggested that appendicitis associated hyperbilirubinemia is due to bacterial translocation into the portal venous system, leading to altered bilirubin excretion. This, in combination with sepsis, may have precipitated AAC in our patient.

It is difficult to diagnose AAC because the findings of right upper quadrant pain, fever, leukocytosis, and abnormal liver tests are not specific. Usually, the ultimate diagnosis of AAC relies on imaging. Early diagnosis will depend on a high index of suspicion in the appropriate patient.[5]

Cholecystectomy is generally considered as the definitive therapy if it can be performed.[6] But for those who could not tolerate the surgery and anesthesia for severe complications, percutaneous cholecystostomy is the preferred choice.[7] Cholecystostomy is generally plausible, rapid, and safe. If cholecystectomy is needed, cholecystostomy may provide time to optimize the patient's condition for surgery, while some patients may recover without further treatment.[8] Few cases have been reported in the English literature to have synchronous AAC and acute appendicitis.[9],[10]

  Conclusion Top

While most of the abdominal pain refers to single diagnosis, clinicians should be aware that more than one diagnosis can rarely still coexist. AAC is a rare clinical entity in young, healthy controls. Prompt treatment of AAC warranted to avoid its complications and high mortality.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Savoca PE, Longo WE, Zucker KA, McMillen MM, Modlin IM. The increasing prevalence of acalculous cholecystitis in outpatients. Results of a 7-year study. Ann Surg 1990;211:433-7.  Back to cited text no. 1
Parithivel VS, Gerst PH, Banerjee S, Parikh V, Albu E. Acute acalculous cholecystitis in young patients without predisposing factors. Am Surg 1999;65:366-8.  Back to cited text no. 2
Huffman JL, Schenker S. Acute acalculous cholecystitis: A review. Clin Gastroenterol Hepatol 2010;8:15-22.  Back to cited text no. 3
Estrada JJ, Petrosyan M, Barnhart J, Tao M, Sohn H, Towfigh S, et al. Hyperbilirubinemia in appendicitis: A new predictor of perforation. J Gastrointest Surg 2007;11:714-8.  Back to cited text no. 4
Owen CC, Jain R. Acute acalculous cholecystitis. Curr Treat Options Gastroenterol 2005;8:99-104.  Back to cited text no. 5
Ginat D, Saad WE. Cholecystostomy and transcholecystic biliary access. Tech Vasc Interv Radiol 2008;11:2-13.  Back to cited text no. 6
Basaran O, Yavuzer N, Selçuk H, Harman A, Karakayali H, Bilgin N. Ultrasound-guided percutaneous cholecystostomy for acute cholecystitis in critically ill patients: One center's experience. Turk J Gastroenterol 2005;16:134-7.  Back to cited text no. 7
Boland GW, Lee MJ, Leung J, Mueller PR. Percutaneous cholecystostomy in critically ill patients: Early response and final outcome in 82 patients. AJR Am J Roentgenol 1994;163:339-42.  Back to cited text no. 8
Sahebally SM, Burke JP, Nolan N, Latif A. Synchronous presentation of acute acalculous cholecystitis and appendicitis: A case report. J Med Case Rep 2011;5:551.  Back to cited text no. 9
Reimann DL, Reeves HG. Concomitance of acute appendicitis and acute cholecystitis. Am Surg 1955;21:220-2.  Back to cited text no. 10


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