Haemocholecyst related to gallbladder malignancy

Case report

A 60-year-old woman was admitted to our institution with right upper quadrant pain for two months and generalised weakness for one month. Her pain was a dull ache and did not radiate to the back. There was no history of fever, jaundice, gastrointestinal bleeding, trauma or bleeding diathesis. She was markedly pale and had a palpable gallbladder. Anaemia was confirmed (Hb 64 g/L). Her performance status was not satisfactory (metabolic equivalent task score <3). Liver function tests were normal, as were her platelet count, prothrombin time, partial thromboplastin time and serum CA19.9. An abdominal ultrasound scan revealed a mass with a heterogenous echo in the region of the gallbladder. This was confirmed by CT scan (Figure 1). The plane between the mass and the adjacent liver was well defined. The biliary tree was normal. Upper gastrointestinal endoscopy and colonoscopy failed to identify any source of blood loss. Three units of blood were transfused before surgery. On exploration, a hugely distended gallbladder filled with blood clots (Figure 2a) with adherent omentum was found. The common bile duct was normal. There was no lymphadenopathy in the hepatoduodenal ligament. The plane between gallbladder and liver was nicely preserved. As there was no obvious clinical suspicion of gallbladder malignancy at exploration, a simple cholecystectomy was performed. Grossly, the gallbladder weighed 195 g, measured 16.5 × 7.6 cm (Figure 2b). Its cut section (Figure 2c) revealed a large amount of clotted blood. There was no gross mucosal abnormality in the pool of blood clots, but an irregularity in the fundus was found. Microscopic analysis revealed an adenocarcinoma, infiltrating into the perimuscular connective tissue (Figure 2d–f). After eight weeks (after improvement of the general condition of the patient and exclusion of disseminated malignancy by positron emission tomography [PET] scan), more radical surgery in the form of wedge resection of the liver and lymph nodal clearance of hepatoduodenal ligament (similar to that of incidentally detected gallbladder malignancy) was performed without demonstration of residual malignancy in the resected specimen. She made an uneventful recovery and received gemcitabine-based chemotherapy and was found to be well at the 21-month follow-up. OPEN IN VIEWER

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Figure 2.

Intraoperative photographs showing: (a) clot filled gallbladder; (b) resected specimen of the clot-filled gallbladder; (c) cut section of the clot-filled gallbladder. (d) Histopathological examination showing sheets of tumour cells destroying muscularis, haematoxylin and eosin (H&E) 40X. (e) Dysplastic mucosa with sheets of pleomorphic cells, H&E 400X. (f) Pleomorphic tumour cells with thin-walled vascular channels, H&E 100X.

Discussion

The term ‘haemocholecyst’ was coined in 1938 to describe haemorrhage into the gallbladder. ¹ Its many causes include gallstones, gallbladder cancer, polyps, cystic artery aneurysm, parasites, ischemia, the presence of heterotopic gastrointestinal mucosa within the gallbladder, coagulation disorder and trauma (including iatrogenic causes, such as liver biopsy and radiofrequency ablation).^2–8 The diagnosis of haemocholecyst is difficult. There is no specific clinical feature. The patient may present with abdominal pain due to distension of the gallbladder or cholecystitis due to obstruction of the cystic duct by blood clots, which depends on the rate of bleeding and the bile flow rate. Despite the fibrinolytic nature of bile, a tendency to form clots in the absence of stones is seen even in instances of minor bleeding. ⁷ These pure clots are more likely to persist and thus lead to cystic duct obstruction, cholecystitis and gallbladder distension.

In our patient, there was no feature suggesting acute cholecystitis. Her weakness was explained by anaemia.

Although, ultrasound and computed tomography (CT) scans may readily identify a gallbladder mass, in the presence of blood clots, definition becomes difficult, as the blood clot appears echogenic. A high-density mass ⁹ may not be found in all cases. Moreover, the association between gallbladder cancer and haemocholecyst may still elude the clinician and only be detected at surgery.

A simple gallbladder haematoma, caused by trauma or a bleeding diathesis, may be handled conservatively. Without such suspected causes, a significant pathology is likely and surgical treatment is recommended. In our case, no carcinoma was identified intraoperatively. Frozen biopsy of the irregular area of the fundus was not sent because the condition of our patient did not warrant acute radical cholecystectomy, which should be considered on a case-by-case basis.