Parastomal cholecystitis

Clinical History

An 82-year-old female patient presented as a surgical emergency with tender abdomen and vomiting.
O/E: Abdominal surgical scarring and irreducible parastomal hernia.
PMHx: Crohn's disease with multiple bowel resections, including hemi-colectomy and RIF stoma; Angina; end-stage Chronic Obstructive Pulmonary Disease requiring NIPPV; depression.
Social Hx: Ex-smoker, lives alone, 3 x day care

Imaging Findings

Chest and Abdominal X-rays were non-specific, with no features of obstruction or perforation.

CT examination following oral and IV contrast in the PV phase demonstrated a parastomal hernia, within which was a distended gallbladder containing stones and surrounding inflammatory change extending into the overlying soft-tissue. The CBD was dilated (22mm) and traceable to an obstructing stone within the head of the pancreas. [Fig. 1a-j]

Management was via a multi-disciplinary approach and initially with IV antibiotics. After 3 days of a regimen discussed with the microbiology department, the patient’s WCC and CRP continued to rise and her condition deteriorated. Surgical approach and ERCP were deemed inappropriate in view of her significant comorbidities. Subsequently, a percutaneous cholecystostomy was performed 3 days after presentation. [Fig. 2a,b]
Though there was an initial improvement in inflammatory markers following this, [Fig. 3a,b] the patient deteriorated and subsequently died from sepsis on day 12 (9 days following percutaneous cholecystostomy).

Discussion

A. Background.
Cholecystitis is not an uncommon disorder with the incidence being approximately the same in Western Europe as in the US, but the exact incidence worldwide is not known. The distribution and incidence follow that of cholelithiasis because of the close relationship between gallstones and acute cholecystitis. In the UK, 17, 559 cases of cholecystitis were reported in the 1-year period between 2010 and 2011, with over half of them being in females. In the same period, 132, 271 cases of cholelithiasis were reported, 2/3 of which were female. [1]
B. Clinical Perspective.
Acute cholecystitis is the most frequent complication of gallstones and occurs in 10% of symptomatic patients. [2] Usually this presents as right upper quadrant pain and can be associated with nausea and vomiting, temperatures, rigors, and elevated inflammatory markers.
Acute calculus cholecystitis accounts for 86% to 95% of cases of acute cholecystitis. [3]
D. Outcome.
The vast majority of these cases respond to intravenous antibiotic therapy and plans can be made to perform an interval cholecystectomy if warranted. In some centres there is a move towards performing a 'hot cholecystectomy.' [4]
Gallbladder in a parastomal hernia is a much rarer condition, with few cases to be found in the literature. [5-8]
E. Teaching Points.
Finding a case with acute calculous cholecystitis in a hernia has not been described in the literature that can be found by this author to date.

Differential Diagnosis List

Final Diagnosis

Acute cholecystitis within a parastomal hernia

URL:	https://www.eurorad.org/case/10400
DOI:	10.1594/EURORAD/CASE.10400
ISSN:	1563-4086