Ann Thorac Surg 2001;72:278-279
© 2001 The Society of Thoracic Surgeons
Case report
Massive hemoptysis from a lung abscess due to retained gallstones
Yaron B. Werber, MDa,
Cameron D. Wright, MDa
a Department of Thoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
Accepted for publication May 20, 2000.
Address reprint requests to Dr Wright, Department of Thoracic Surgery, Massachusetts General Hospital, 55 Fruit St, Blake 1570, Boston, MA 02114
e-mail: wright.cameron{at}mgh.harvard.edu
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Abstract
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This case report describes a subhepatic abscess from spilled gallstones which eroded through the diaphragm causing a right lower lobe pulmonary abscess and presenting as massive hemoptysis.
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Introduction
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Laparoscopic cholecystectomy has become the procedure of choice for patients with gallstone disease requiring surgical intervention. Although the procedure is safe and cost-effective, a rather common occurrence intraoperatively is gallbladder rupture secondary to inadvertent laceration. Spillage of gallstones into the peritoneal cavity ensues and removal of all the gallstones is time consuming and difficult. On rare occasions, an abscess arises from the retained gallstones.
A 64-year-old woman underwent a laparoscopic cholecystectomy in November 1998 for acute cholecystitis. An acutely inflamed gallbladder with marked adhesions was identified, and dissection was difficult. During the procedure, the gallbladder contents were suctioned out, yet numerous gallstones were spilled. The peritoneal cavity was searched, many gallstones were retrieved, and the cavity was irrigated with copious amounts of saline. The patient did well postoperatively and was discharged home on day 2.
One month later, the patient developed a low-grade fever associated with chills, night sweats, weight loss, and fatigue. An abdominal computed tomographic (CT) scan was obtained and was erroneously interpreted as showing no specific pathology. At that time, the right lung base was normal. During the next 4 months, her symptoms worsened, and a chest, abdomen, and pelvis CT scan revealed a 3.0-cm rounded mass with spiculated borders in the right lower lobe of the lung. A CT-guided percutaneous needle biopsy showed focal chronic inflammation. The patient was placed on a 2-week course of trovafloxacin with symptomatic relief. Cultures were negative.
Over the next 6 weeks, the patient developed the new onset of right pleuritic chest pain with mild dyspnea and cough, along with an overall exacerbation of her on-going symptoms. In April 1999, the patient experienced the sudden onset of one-half cup bright-red hemoptysis and immediately presented to the emergency room with ongoing hemoptysis. On physical exam, the patient had a low-grade temperature and was tachycardic and tachypneic. Rales were appreciated in the right lung base. Laboratory results showed a white blood count of 9.8 x 109/L and an erythrocyte sedimentation rate of 67 mm/hr. Chest radiographs revealed a 2.0-cm x 4.0-cm parenchymal density in the right base. Chest CT scan demonstrated the same 3.0-cm lesion at the posterior basal segment of the right lower lobe contiguous with the posterior right hemidiaphragm and a phlegmonous change in the right subhepatic space (Fig 1). A calcified density, consistent with gallstones, was seen in the center of the phlegmon (Fig 2). In retrospect, this density was seen on the previous CT exams of December 1998 and March 1999, but was not noted. Bronchoscopy was performed, which showed brisk fresh bleeding originating from the lateral and posterior segments of the right lower lobe. A presumptive diagnosis of subhepatic abscess eroding through the diaphragm and causing a lung abscess was made.
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Fig 1. Computed tomographic scan demonstrating a 3-cm right lower lobe lung mass on the diaphragmatic surface of the lung (arrowhead).
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Fig 2. Computed tomographic scan done at the same time as Figure 1, slightly lower, demonstrating a poorly-defined collection in the subhepatic space (black arrowhead) with a calcified gallstone (white arrowhead).
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A right thoracotomy was performed, which revealed a 4.0-cm right lower lobe abscess with attachment to the right hemidiaphragm. The lung lesion was dissected off the diaphragm and a right lower lobe wedge resection was undertaken. Upon further exploration, a 1-cm x 1-cm x 2-cm purulent subhepatic abscess was uncovered, harboring 15 pigmented gallstones measuring up to 7 mm. The subhepatic space was curretted, irrigated, and obliterated with sutures which also closed the diaphragmatic defect. Cultures grew predominantly Klebsiella pneumoniae and Escherichia coli. The patient was discharged home on postoperative day 4 on a course of oral ciprofloxacin. The patient was well 5 months later.
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Comment
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Over 80% of patients with gallstone disease are treated laparoscopically [1]. A large report of laparoscopic cholecystectomy demonstrated a 9% incidence of gallbladder laceration associated with a 1% rate of stone spillage. Another report of laparoscopic cholecystectomy reported a conversion rate of 35 of 77,604 to an open procedure to retrieve spilled stones. In that report, only 6 patients developed serious abdominal infections because of the retained stones [2]. It was concluded that spillage of stones is not an indication for conversion to open laparotomy and is inconsequential.
In our review of the literature, we found many descriptions of retained gallstones causing intraabdominal abscesses and draining sinuses [1]. Additionally, we encountered descriptions of subdiaphragmatic abscesses causing pleural effusions necessitating a chest tube or thoracotomy for drainage [3, 4]. Other authors described lost gallstones presenting with cholelithoptysis or empyema [5, 6]. In view of these increasing numbers of reports discussing the complications of retained gallstones, all efforts should be taken to avoid gallstone spillage.
We report a subhepatic abscess eroding through the diaphragm causing a pulmonary abscess and resulting in massive hemoptysis from gallstones. Despite our patient being seen by several physicians over a period of 7 months, the correct diagnosis was overlooked because of failure to consider the complications of retained gallstones. We advocate that retained gallstones should be documented in the medical record so that rare cases of abscess formation can be diagnosed and treated early in their course. Treating physicians should be aware that retained gallstones can present with complications requiring urgent thoracic surgical management.
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References
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Leslie K.A., Rankin R.N., Duff J.H. Lost gallstones during laparoscopic cholecystectomy: are they really benign?. Can J Surg 1994;37:240-242.[Medline]
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Downie G.H., Robbins M.K., Souza J.J., Paradowski L.J. Cholelithoptysis: a complication following laparoscopic cholecystectomy. Chest 1993;103:616-617.
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Stockberger S.M., Kesler K.A., Broderick L.S., Howard T.J. Bronchoperitoneal fistula secondary to chronic Klebsiella pneumoniae subphrenic abscess. Ann Thorac Surg 1999;68:1058-1060.[Abstract/Free Full Text]
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Lee V.S., Paulson E.K., Libby E., Flannery J.E., Meyers W.C. Cholelithoptysis and cholelithorrhea: rare complication of laparoscopic cholecystectomy. Gastroenterology 1993;105:1877-1881.[Medline]
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Chopra P., Killorn P., Meharan R.J. Cholelithoptysis and pleural empyema. Ann Thorac Surg 1999;68:254-255.[Abstract/Free Full Text]
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Abstract
Introduction
