HAEMORRHAGIC ACALCULUS CHOLECYSTITIS
Shakthi K Kumar*, Simran Singh*, Mary Latha Williams**,D Venugopala***, M Paul Korath****, K Jagadeesan*****
*DNB Resident, Radiodiagnosis; **DNB Resident, General Surgery; ***Registrar in Medicine; ****Chief Physician; *****Director, KJ Hospital.
A Sixty two year old female a known case of carcinoma of left breast T2 N1 M0 was admitted for mastectomy with axillary clearance. She was a known case of Rheumatic valvular heart disease who has been having chronic atrial fibrillation moderate severe mitral regurgitation, mild mitrial stenosis with mild to moderate pulmonary hypertension and mild tricuspid regurgitation. She has been on regular medication which included ionotrope, diuretic, class III antiarrhythmic agent and oral anticoagulant.
Laboratory work up revealed normal haematological, biochemical profile and liver function tests. Coagulation profile was within normal limits. Chest skiagram revealed cardiomegaly. Ultrasonography (USG) of abdomen revealed normal appearing liver, gall bladder (GB), spleen. Liver and bone scintigraphy were normal. The computed tomography of the brain was normal.
Transthoracic echocardiography with doppler study did not reveal any significant change in severity of valvular lesion or gradient across the valves respectively. However a clot in left atrium (LA) was detected. The oral anticoagulant was suspended two days prior to surgery as per anaesthesiologistís advice.
Fig 1 Fig 2 Ultrasound scan showing a normal gall bladder pre operative Ultrasound scan showing distended gall bladder with wall thickening and sludge.
Fig 3 Echo showing a left atrial thrombus.
After adequate preparation and infective endocarditis prophylaxis she underwent elective left mastectomy with axillary clearance surgery under general anaesthesia. During the immediate post operative period she had no untoward cardiac events. The physician and the cardiologist who evaluated the patient felt she had to be put on heparin therapy in view of the presence of LA clot detected on transthoracic echocardiography and atrial fibrillation. Intermittent intravenous heparin was started on the second postoperative day along with oral anticoagulant and other regular medications. Partial thromboplastin time PTT was closely monitored before giving each dose of heparin. On the fourth post operative day patient developed severe right upper quadrant pain. Physical examination revealed anxious patient, PR 92/mt, irregularly irregular, all accessible peripheral pulses were well felt. Average BP 110/80 mmHg. RR 28/mt. There was no pallor, icterus, or cyanosis, no petechial rashes or ecchymoses. On examination of abdomen the gall bladder was palpable, tender and firm in consistency. Bed side ultrasound scan of abdomen showed distended gall bladder measuring 8.7 x 3.3 cm size with wall thickness of 6 mm (earlier USG scan study of GB was normal). There were multiple echogenic areas with sludge. She was treated initially conservatively with ampicillin and sulbactum combination and amikacin.
However on the sixth post operative day her pain abdomen worsened pulse rate increased, total leucocyte count rose to 19,000/cumm with predominant polymorphonuclear leucocytes. She was taken up for emergency cholecystectomy surgery. On opening the abdomen gall bladder was enlarged and looking beefy red, cholecystectomy surgery was done under general anaesthesia.
Post operatively patient made uneventful recovery. The histopathological study of excised gall bladder and macroscopic examinations showed multiple haemorrhagic areas. On section inner wall of GB was bile stained and on the surface blotchy haemorrhagic areas were seen. There was no macroscopic evidence of suppuration made out. Microscopic study showed denuded GB mucosa with large areas of haemorrhage extending transmurally upto the serosa confirming the diagnosis of acute haemorrhagic cholecystitis.
Haemorrhagic cholecystitis is a rare condition occurring after surgical and non surgical trauma. Its occurrence has been reported most commonly after cardiac surgery and the use of anticoagulants. 
The symptoms are commonly pain in the hypochondrium and some times in the epigastrium. Common presentations are abdominal pain 100%, leucocyte 74% and fever 63%.  Our patient had pain in the epigastrium on the second post operative day without an enlarged GB. The second episode of abdominal pain was in the right hypochondrium with grossly enlarged GB. Haemorrhagic cholecystitis has been described as occurring due to bleeding from the branches of the cystic arteries within the GB.  Connection of the blood vessels with the intra and extrahepatic biliary system leads to haemobilia. The sonographic findings of haemorrhagic cholecystitis reported by Chinn et al are (I) focal GB wall irregularity, (II) intraluminal membranes and (III) coarse non mobile intraluminal echoes. 
Our patient had GB wall thickening and few internal echoes. The WBC count increased from 10,000 to 22,000/cumm. The dose of anti-coagulation used in this case was 5000 mts IV 6 hrly to prevent thromboembolism in view of the left atrial thrombus and the atrial fibrillation. The INR was in the range of 1.27 to 1.55 which was well within the therapeutic range. The microscopic examination of the GB showed large areas of haemorrhage extending transmurally upto the serosa confirming the diagnosis of haemorrhagic cholecystitis.
We report the case because of its rarity. The early diagnosis depends on the high degree of suspicion as delay in diagnosis greatly increases the mortality. This condition though commonly reported after cardiac surgery can occur after other surgeries as well especially when post operative anticoagulation is used.