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A large abdominal wall abscess as a presentation of gallstone disease in an elderly woman
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  1. Ojone Hannah Illah
  1. Warwick Medical School, Coventry, UK
  1. Correspondence to Ojone Hannah Illah, o.h.illah{at}warwick.ac.uk, ojillah{at}hotmail.com

https://doi.org/10.1136/bcr-2013-201476

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    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.

    Figure 1
    Figure 1

    (A) Abdominal wall abscess visible as large (clinically ∼15×12 cm) swelling in right upper quadrant (B) MR cholangiopancreatography image showing multiple stones in the gallbladder (GB), a stone in the common bile duct (arrow) and a part of the abdominal wall abscess.

    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.

    Figure 2
    Figure 2

    (A) Axial CT image showing the gallbladder (GB) connection with the abdominal wall abscess. (B) Coronal CT image showing the same as (A) with a better view of the abnormal tract (arrow).

    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.1 The pathophysiology of these conditions starts with a gallstone obstructing the gallbladder2; 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.2 ,3 More commonly, the gallbladder fistulates with adjacent viscera or perforates into the peritoneum.1

    Management includes antibiotics, abscess drainage and elective cholecystectomy with excision of the abnormal tract.1 Co-morbidities in the predominantly elderly group affected by these conditions may make surgery unfeasible; in such cases, repeated drainage of the cholecystocutaneous abscess may be required.

    Learning points

    • Gallbladder perforation from neglected gallstone disease can present as an abdominal wall abscess or fistula (cholecystocutaneous fistula).

    • This is rare and most commonly encountered in elderly patients with multiple comorbidities where surgical management may not be feasible.

    • Timely surgical management of gallstone disease can prevent the occurrence of this complication.

    Acknowledgments

    The author would like to thank J Gilmour, O Hager and Dr A Palit for their help in providing a better understanding of the case and the images.

    References

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      . Spontaneous cholecystocutaneous fistula: a rare presentation of gallstones. J Surg Case Rep 2010;2013:5.
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      1. Carragher AM,
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      . Subcutaneous herniation of gall-bladder with spontaneous cholecystocutaneous fistula. Clin Radiol 1990;2013:283–4.
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      1. Sanjay M,
      2. Rajesh G,
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      . Spontaneous gallbladder perforation presenting as abdominal wall abscess. Internet J Surg 2007;2013:2.
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    View Abstract

    Footnotes

    • Contributors OHI was involved in the drafting and editing of the manuscript.

    • Competing interests None.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.