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Necrotising fasciitis of abdominal wall following rupture of reconstituted remnant gallbladder
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  1. Zi Qin Ng,
  2. Oscar Brett and
  3. Luc Delriviere
  1. Department of General Surgery, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
  1. Correspondence to Dr Zi Qin Ng; kentng{at}hotmail.co.uk

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Description

A man in his 80s presented to emergency department with ongoing swelling and redness around the right upper quadrant abdominal wall. One week prior to current presentation, he had a fall and landed onto the right side of abdominal wall (figure 1A). As a result, he sustained right-sided rib fractures that was managed conservatively. His medical history includes compensated liver cirrhosis (Childs-Pugh B), laparoscopic subtotal cholecystectomy for cholecystitis 7 years ago and diabetes mellitus.

Figure 1

(A) Clinical picture showing the swelling and erythema around the right upper quadrant. (B) Axial slice of CT of the abdomen showing the fat stranding around the subcutaneous tissue with gas locules (red arrow) at the abdominal wall concerning for necrotising fasciitis with (C) a collection extending into a remnant gallbladder (green arrow).

On arrival, his vital signs were stable and afebrile. Clinical examination revealed a 10×5 cm erythematous and tender swelling at his right upper abdominal wall (figure 1A).

Biochemistry showed elevated white cell count 13×109/L, C reactive protein 189 mg/L, bilirubin 42 µmol/L, alanine transaminase (ALT) 26 U/L, alkaline phosphatase (ALK) 220 U/L, gamma-glutamyl transferase (GGT) 184 U/L and albumin 20 g/L. CT of the abdomen/pelvis revealed fat stranding around the subcutaneous tissue with gas locules at the abdominal wall concerning for necrotising fasciitis (figure 1B) with a collection extending into a remnant gallbladder (figure 1C).

He was resuscitated and commenced on broad spectrum intravenous antibiotics. He underwent urgent debridement of the necrotic abdominal wall with drainage of the abscess. There was no frank bile but there was extension of the collection intraperitoneally. The microbial culture grew Escherichia coli. A drain was left in situ and the wound was packed. During a wound dressing change postoperatively, a gallstone was noticed. A follow-up CT scan on day 5 postoperation showed complete resolution of the collection and the drain was located at the gallbladder fossa (figure 2). He subsequently went for rehabilitation and has recovered well on outpatient follow-up 6 weeks later.

Figure 2

(A) Coronal and (B) axial slices of CT of the abdomen showing complete resolution of the collection at day 5 postoperation with the drain sitting at the gallbladder fossa (green arrow).

His previous MRI performed 36 months ago for surveillance of liver cirrhosis was reviewed, which showed an enhancing cystic nodule at the gallbladder fossa (figure 3A). Subsequent fluorodeoxyglucose-positron emission tomography scan showed mild uptake of the cystic nodule but there was intense uptake of a nodular lesion anterior to the gallbladder fossa (figure 3B). Surveillance imaging showed stable appearance. In retrospect, this represented a reconstituted gallbladder following subtotal cholecystectomy with a dropped gallstone at the abdominal wall.

Figure 3

(A) Axial slice of MRI of the liver showing an enhancing cystic nodule at the gallbladder fossa (green arrow). (B) Axial slice of the positron emission tomography-CT showing mild uptake of the cystic nodule but there was intense uptake of a nodular lesion (blue arrow) anterior to the gallbladder fossa.

Perforated gallbladder is extremely rare, moreover, from reconstituted remnant gallbladder. The true incidence of symptomatic remnant gallbladder following subtotal cholecystectomy is unknown. It is expected to increase due to advocacy of subtotal cholecystectomy in surgical training in difficult cases (eg, frozen Calot’s triangle and cirrhotic liver with varices) to prevent biliary tree injury.1–3 Its symptoms mimic those of biliary colic.

In this case, it is possible that the patient has had a fall with concomitant cholecystitis of the remnant gallbladder, leading to localised perforation contained to the abdominal wall and then necrotising fasciitis of the abdominal wall. The main principles of management are resuscitation, early administration of antibiotics, aggressive debridement and plan for relook in 24–48 hours. The presentation of the patient is uncommon. Nevertheless, with increased rates of subtotal cholecystectomy performed, clinicians should be vigilant about re-presentation of the symptoms of remnant gallbladder as 71% of the subtotal cholecystectomy is not reported or disclosed, which often can lead to delayed diagnosis and misdiagnosis.4 Clinicians should also be aware of potentially dropped gallstones, which could present in a myriad of presentations.5

Learning points

  • It is expected to face more patients with symptoms associated with remnant gallbladder following subtotal cholecystectomy.

  • The diagnosis is often delayed as patients are often not informed regarding subtotal cholecystectomy and clinicians are not aware.

  • The key management for necrotising fasciitis consists of early recognition, resuscitation, broad-spectrum antibiotic administration and debridement for good outcomes.

Ethics statements

Patient consent for publication

References

Footnotes

  • Contributors ZQN—study design, data collection and analysis, and drafting of the manuscript. OB—data collection and analysis, and review of the manuscript. LD—data analysis, review of the manuscript and supervision.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.

  • Competing interests None declared.

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