Bowel hath no fury like a gallbladder inflamed
A 73-year-old male, Mr B presented to the A&E at Whipps Cross Hospital, London with a 3-day history of suprapubic pain. It was associated with some abdominal distension and bloating, and had no aggravating or relieving factors. Additionally, Mr B reported three episodes of non-projectile, non-bilious and blood-free vomiting. He had not opened his bowels for the past 5 days, but had been passing flatus. He denied any urinary symptoms, weight loss or change in bowel habit, prior to this acute episode. He was otherwise fit and healthy, had no previous surgeries and was on no medication. On examination, he was vitally stable but appeared to be dehydrated. He was tender and had guarding in the suprapubic region. He also had increased bowel sounds and was excessively tympanic on percussion of the abdomen. An inguinal hernia on the left side was noted but was reducible and non-tender.\nHis blood on admission showed a raised white cell count of 12.5 × 103 cells/ml (with neutrophilia) and a C-reactive protein of 14.0 mg/l. His alanine transaminase was mildly raised at 79 U/l; however, his remaining liver and renal function tests were normal. His abdominal X-ray showed dilated loops of small bowel but no evidence of large bowel dilatation (Fig. ). A provisional diagnosis of small bowel obstruction was made and a computerised tomography (CT) scan of the abdomen and pelvis was ordered. The CT showed multiple dilated loops of small bowel but no focus of obstruction (Fig. a). The gallbladder wall was thickened and oedematous and there was also evidence of gas within its lumen. Air was seen under the left lobe of the liver, suggestive of a bowel perforation. Furthermore, in Fig. b, the second part of the duodenum appears to be adherent and in communication to the gallbladder. Putting all these findings together, the radiologist felt that there was acute cholecystitis leading to a duodenal perforation and paralytic ileus.\nA plan for a laparotomy was made and the patient was taken to theatre. Intra-operatively, the entire small bowel up to the ileocaecal valve was dilated with no evidence of mechanical obstruction.\nThe colon was dilated up to the hepatic flexure; from there onwards it was progressively collapsed. The hepatic flexure of the colon was adherent to a chronically inflamed and necrotic gallbladder. The gallbladder was friable and adherent to the first part of the duodenum. A subtotal cholecystectomy was performed due to the multiple adhesions of the gallbladder and when perforated and removed, multiple cholesterol gallstones were released. The cholecystitis had eroded a small perforation into the first part of the duodenum as well, which was repaired with an omental patch. The abdomen was washed out and a Robinson's drain left in situ. The patient recovered uneventfully and was discharged on the seventh post-operative day. The results of the histopathology of the gallbladder revealed inflammation and no malignant cells.