Haemoperitoneum following gallbladder necrosis.

Acute cholecystitis is usually treated conservatively, and surgery performed electively. Complications of cholecystitis such as empyema and perforation may be difficult to diagnose preoperatively. Delay in diagnosis and subsequent operative intervention results in increased morbidity and mortality. Prompt recognition and management are necessary to improve the outcome. CASE REPORT. A 54-year-old mentally handicapped man was admitted with a one week history of vomiting, rigors and periumbilical pain. Initially he was well, haemodynamically stable and not clinically anaemic, jaundiced or pyrexic. His abdomen was soft, with slight tenderness in the right hypochondrium and 4 cm of hepatomegaly. Four hours later he suddenly became shocked, pulse rate 120 per minute, blood pressure 70/0 mmHg. He developed abdominal guarding with rebound tenderness , and bowel sounds were absent. Haemoglobin was 5-6 g/dl, white cell 31,000. Serum sodium, urea, potassium and amylase concentration were normal. Liver function tests were mildly elevated, serum bilirubin 15 mmol/l (3-18), gamma glutamyl transpeptidase 141 mmol/l (7-64), asparate transaminase 140 mmol/l (10-42), and alkaline phosphatase 171 mmol/l (26-88). Emergency laparotomy revealed a malodorous mass of necrotic tissue and fresh clot around the gallbladder bed and there were two litres of blood in the peritoneal cavity. No gallbladder tissue or gallstones were found. There was a brisk ooze from the cavity in the liver, but no definite bleeding point could be identified. The clot and free blood were removed, saline and tetracycline lavage was performed and the area packed. At a second laparotomy 36 hours later the packs were removed uneventfully. Histopathological examination of the necrotic mass showed no evidence of gallbladder tissue. Preoperative blood cultures had grown streptococcus faecalis; he was treated with intravenous gentamicin, penicillin and metronidazole with good clinical response. Postoperatively he recovered well and went home three weeks later. On abdominal ultrasound scan six months later a gallbladder remnant was not visualised.