A 70-year-old man presented to the accident and emergency department with a 1-day history of right upper quadrant pain and nausea. Examination revealed mild tenderness in the right upper quadrant but no evidence of peritonism or haemodynamic instability. The patient was admitted to the general surgical ward with a diagnosis of cholecystitis and remained stable overnight. In the morning, he developed acute severe pain in the upper abdomen. Examination found him to be tachycardic, tachypnoeic and to have peritonism in the upper abdomen. An urgent CT scan demonstrated cholecystitis but also a small amount of fluid in the pelvis, with Hounsfield units suggestive of blood. The patient proceeded to laparotomy and was found to have massive haemoperitoneum secondary to intrahepatic gallbladder perforation causing liver capsule tear. Cholecystectomy was performed and the liver packed until haemostasis was achieved. The patient made an uneventful recovery.
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