A large abdominal wall abscess as a presentation of gallstone disease in an elderly woman.

To cite: Illah OH. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2013201476 DESCRIPTION An 80-year-old woman presented with a large recurrent abdominal wall abscess in the right upper quadrant (figure 1A) with no associated symptoms. Her medical history revealed one previous episode of cholecystitis with gallstones 8 years ago, which resolved without surgical intervention. Other comorbidities include osteoarthritis, obesity, hypercholesterolaemia and hypertension. Previous MR cholangiopancreatography (figure 1B) and CT scans (figure 2A,B) showed a subcutaneous abdominal collection communicating with the gallbladder, gallstones and mild intrahepatic and extrahepatic duct dilation. Prior management had consisted of ultrasound and CT-guided abscess drainage, which produced large amounts of pus containing multiple gallstones (clinically). Endoscopic retrograde cholangiopancreatography was subsequently performed with stone removal and sphincterotomy. Cholecystocutaneous abscesses and fistulae, being rare complications of neglected cholecystitis and cholelithiasis, are hardly encountered today due to improved diagnosis, antibiotic therapy and surgical management of gallstone disease. The pathophysiology of these conditions starts with a gallstone obstructing the gallbladder; this results in increased pressure within the gallbladder, and sets off an inflammatory cascade potentially leading to necrosis and perforation. A localised abscess may be formed which may rarely fistulate with the abdominal wall resulting in a cholecystocutaneous abscess; if this perforates, a cholecystocutaneous fistula is formed. 3 More commonly, the gallbladder fistulates with adjacent viscera or perforates into the peritoneum.