A pancreatic pseudocyst is a collection of amylase-rich fluid enclosed in a well-defined wall of fibrosed granulation tissue. It typically arises several weeks after the onset of acute pancreatitis, in the context of chronic pancreatitis or pancreatic trauma. This is a case of a 25-year-old man with pancreatic pseudocyst and underlying cholelithiasis. Patient developed a perforation of gallbladder, secondary to empyema, which imitated a pseudocyst rupture due to which his condition deteriorated further. The patient required surgical intervention.

Keywords: Pancreatic Pseudocyst; Gallstone Perforation; Cystogastrostomy.

Copy right Statement: Content published in the journal follows Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0). © Zaidi MZ (2024).

Citation: Zaidi MZ; Zainab K; Aslam G; Sabir AR; Iqbal M; et.al.,. Perforated Empyema Gallbladder Mimicking Ruptured Pancreatic Pseudocyst. J Clin Med Images Case Rep. 2024; 4(1): 1656.

A 25-year-old male patient presented to the ER in a critical condition with severe pain in the abdomen, nausea and vomiting one day back. Pain in the epigastrium was sudden, stabbing, non-radiating in nature, associated with shortness of breath and vomiting, relieved by sitting forward and analgesics, and aggravated by food. He had 8-10 episodes of vomiting after pain on first day, watery in consistency with digested and undigested food particles. Patient had unrecorded fever spikes as well. He had no previous comorbidities or systemic symptoms. On examination patient was of average height and weight who was vitally stable but looked pale and lethargic. His abdomen was distended with tender epigastrium hence not allowing any mass to be appreciated. CT scan showed severe acute necrotising gallstone pancreatitis which according to Balthazar classification was score 9 i.e., >50% necrosis with peri pancreatic collections. The patient was managed in high dependency unit with broad spectrum anti-biotics and strict diet control. Patient had infrequent fever spikes during initial management. A follow up CT scan after 6 weeks showed a maturing pancreatic pseudocyst (measuring 10.7 x 7.8 cm) compressing the stomach along with complete necrosis of body and tail of pancreas. The patient was scheduled a combined laparoscopic cystogastrostomy and cholecystectomy. During this time the patient developed acute abdomen with high grade fever, leucocytosis, and abdominal tenderness. Table 1 shows the serology results of the patient.

Ultrasound was done that showed a pericholecystic collection which implied the cyst has ruptured. Due to the urgent condition the patient was planned for an exploratory laparotomy and washout. A CT scan was advised on the morning of surgery which strikingly showed an intact pseudocyst but an inflamed perforated gallbladder with pericholecystic collection (see Figure 1). Due to this new development, the patient was planned for exploration and underwent an open cystogastrostomy and cholecystectomy and drainage of abdominal cavity.

Table 1:

Figure 1: CT scan showing perforated gall bladder (red arrow) and intact pseudocyst (blue arrow). A: Coronal view; B: Tranverse view.

Figure 2: A and B: arrow showing necrotic pancreas through the posterior wall of stomach (open cystogastrostomy)
C: arrow showing perforation of inflammed gall bladder

Treatment and follow-up: During the surgery, pseudocyst was drained and sent for cytology. The necrosed parts of the pancreas were removed via piece debridement (see Figure 2). The gallbladder was adherent to the colon, there was a large amount of pus and stones in the abdominal cavity. Serosal tear of colon was repaired, and retrograde cholecystectomy was done. Cholangiogram was done post operatively to confirm that common bile duct was intact. Patient had a smooth post operative course and ultrasound was negative for post operative peritoneal collections. He was discharged on the 5th post-op day.

According to the updated Atlanta classification of collections associated with acute pancreatitis , this case represents fluid collections in interstitial edematous pancreatitis. A pancreatic pseudocyst is a complication of acute or chronic pancreatitis but the prevalence of pseudocyst in chronic pancreatitis (41.8%) is more than that in acute pancreatitis (14.6%) . Moreover, it more commonly arises in alcoholic chronic pancreatitis (70%-78%) followed by biliary pancreatitis (6%-8%). Most of the pseudocysts resolve spontaneously within 6 weeks but are unlikely to resolve if persist beyond 6 weeks [3].

In 3-5 % cases [4], pseudocyst rupture spontaneously through the GI tract lumen or in the peritoneal cavity with the onset of pancreatic ascites and severe peritonitis. To reduce rupture chances, these patients are managed with strict dietary precautions such as low-fat diet and fluid therapy. Same was the case in this patient who was tolerating liquids only. However instead of any complication related to pseudocyst rupture he developed gallbladder perforation which was unlikely in these circumstances [5]. Gallbladder perforation is reported in diabetics, obese, hypertensive, old aged, immunocompromised [6] patients. This case did not have these risk factors. As Hayrullah Derici et al [7]. reported in his case report such factors are significant for gallbladder perforation. Moreover, such a case of gallbladder perforation where pseudocyst has no pressure symptoms on gallbladder is a rare undocumented event [8]. Ideally a laparoscopic approach to internal drainage of pseudocyst and cholecystectomy is done and has favourable results with reduced morbidity.

In this case due to the development of gallbladder perforation an open cystogastrostomy and cholecystectomy was opted to prevent future peritoneal irritation and recurrence of pseudocyst. Lora Melman et al., in a case series concluded that laparoscopic and open cystogastrostomy have equivalent success rates [9]. There are different reports about the recurrence of pseudocyst after open cystogastrostomy, but most agree that the rate is less than 1% and open is as good as minimally invasive surgery with a good survival rate [10,11]. Although rare, gallbladder perforation can occur with an intact pancreatic pseudocyst. This report might be helpful in early diagnosis and management of patients with similar presentation.

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