Haemorrhagic Cholecystitis

Haemorrhagic cholecystitis is acute gallbladder inflammation with bleeding into the lumen or wall. Clots can obstruct the cystic duct or enter the bile duct, causing jaundice or haemobilia.

It is uncommon and mainly reported in older patients, in those taking anticoagulants or antiplatelet drugs, and in those with cirrhosis, kidney failure or other coagulopathy. Other causes are trauma, tumours, cystic artery pseudoaneurysm and gallstone erosion. Mortality is higher than for ordinary cholecystitis, mainly from comorbidity.

Pathophysiology.

Mucosal ischaemia and ulceration, together with impaired haemostasis, cause bleeding into the gallbladder. Distension from clot raises wall pressure and leads to necrosis, perforation or biliary obstruction by clot.

Right upper quadrant pain, fever, nausea, jaundice, haematemesis or melaena (haemobilia), anaemia and shock in massive bleeding.

Red flags.

• Haemodynamic instability.
• Falling haemoglobin.
• Jaundice with cholangitis from clot in the duct.
• Anticoagulant use with abdominal pain.

Ultrasound shows echogenic non-shadowing material (clot) in the gallbladder, sometimes layering. CT shows dense lumen contents (over 50 Hounsfield units) and contrast blush when bleeding is active. Send full blood count, clotting, platelets, renal and liver tests, and blood cultures. Mesenteric angiography locates and treats the bleeding vessel. Endoscopy excludes other sources of upper gastrointestinal bleeding and may show blood from the ampulla.

Differential diagnosis.

• Uncomplicated acute cholecystitis.
• Gallbladder cancer.
• Gallbladder polyp or sludge.
• Cystic artery pseudoaneurysm.
• Other causes of haemobilia.
• Peptic ulcer bleeding.

Resuscitate, stop anticoagulant and antiplatelet drugs when safe and reverse coagulopathy. Transfuse at haemoglobin 70 g/L (80 g/L with cardiovascular disease). Cholecystectomy is the definitive treatment. Angiographic embolisation controls bleeding in patients unfit for surgery or with a pseudoaneurysm.

• Phytomenadione (vitamin K): 5 to 10 mg IV slowly over 20 minutes, repeated after 12 to 24 hours if INR remains raised; maximum 10 mg in a single dose; monitor INR and for hypersensitivity; use the lower dose in older adults.
• Prothrombin complex concentrate (warfarin reversal with life threatening bleeding): 25 to 50 units/kg IV once, with vitamin K; maximum 5,000 units; monitor INR at 30 minutes and for thrombosis; avoid in heparin induced thrombocytopenia.
• Piperacillin-tazobactam (cholecystitis or infected clot): 4.5 g IV every 6 hours for 4 to 7 days after source control; maximum 18 g daily; monitor renal function and counts; reduce for creatinine clearance under 40 mL/min.

Clear clot from the bile duct by endoscopic retrograde cholangiopancreatography with sphincterotomy when cholangitis or obstruction occurs.

Monitoring. Haemoglobin every 6 hours until stable, clotting, vital signs and liver tests.

Referral and escalation. Surgery, interventional radiology and critical care; haematology for reversal in complex anticoagulation.