Paper 9 Surgery June 2021 Mechanical small bowel obstruction secondary to acute cholecystitis in the context of an irreducible inguinal hernia: a case report Alessandro SgrÒ1,2, Joshu McIntyre1, Andreas Luhman1 1 Department of General Surgery, Victoria Hospital, Kirkcaldy, UK 2 Department of Clinical Surgery, The University of Edinburgh, Edinburgh, UK Corresponding Author: Mr Andreas Luhman Department of General Surgery Victoria Hospital Hayfield Road Kirkcaldy, Fife KY2 5AH, UK E-mail: [email protected] Contributions: All authors were involved in the clinical management of this case, drafted the manuscript and approved the final version. Sources of Funding: None Conflicts of interest: None Running title: Small bowel obstruction in acute cholecystitis Abstract: We report the case of a 78-year-old man who presented to the emergency department with a picture of small bowel obstruction in the presence of an incarcerated inguinal hernia. Intraoperatively the cause of the obstruction was found to be a pericholecystic abscess originating from a perforated gallbladder. This case is a useful learning tool in order to consider the range of aetiologies in small bowel obstruction, as well as the possibility of dual pathology and complex surgical decision making. Keywords: Bowel obstruction, cholecystitis, abscess 1 ASGBI SURGERY ASGBI SURGERY Paper 9 Paper 9 June 2021 June 2021 Introduction Small bowel obstruction (SBO) is a frequent emergency presentation. The most common aetiologies are adhesions and hernias1. Management is often conservative, but patients with non-settling obstruction, closed loop bowel obstruction, bowel perforation or bowel ischaemia require surgery1. We report an unusual cause of SBO due to perforated acute cholecystitis with surrounding perichole- cystic collection causing mechanical SBO. In addition, an apparently incarcerated inguinal hernia caused diagnostic difficulties. This case serves as an unusual example of SBO in the presence of distracting dual pathology. Case Report A 78-year-old man presented to the emergency department with a 24-hour history of generalised, cramp-like abdominal pain, vomiting and abdominal distension. He reported constipation for the prior ten days. His past medical history included atrial fibrillation (on Edoxaban), severe mitral valve regurgi- tation, hypertension, pulmonary hypertension, and right heart failure. He had no previous history of ab- dominal surgery. On admission his vital signs were: temperature 36.8°C, heart rate 83bpm, blood pres- sure 108/42mmHg, O2 saturation 95% on air, respiratory rate 24bpm. On examination, his abdomen was distended with tenderness in the right upper quadrant (RUQ). An irreducible right inguinal hernia was present. Blood tests revealed leucocytosis (white cell count 24.6 × 109/L, range 4-10 × 109/L), raised C re- active protein (311.8 mg/L, range 0-5 mg/L) and acute kidney injury (creatinine 232 Umol/L - range 50/120 Umol/L, urea 21.2 mmol/L - range 2.5-7.8 mmol/L, estimated glomerular filtration rate 24 mL/min/1.73 m2). Figure 2: The CT of the abdomen and pelvis showing small bowel dilatation, a right inguinal hernia containing a distended loop of bowel, a small fluid collection in the RUQ next to the hepatic flexure Abdominal X-ray demonstrated SBO (Figure 1). Computed Tomography (CT) of abdomen and pelvis with and a distended gallbladder. intravenous contrast showed a right inguinal hernia containing a distended loop of bowel with features of incarceration (Figure 2). The final CT report indicated that these appearances were consistent with SBO secondary to an incarcerated inguinal hernia. A small fluid collection in the RUQ next to the hepatic flexure and a distended gallbladder were also noted (Figure 3). However, these findings were deemed not of clinical significance by the reporting radiologist. Figure 1: The X-ray of the abdomen showing small bowel obstruction. Figure 3: The CT of the abdomen and pelvis showing the small bowel entrapped in the inflammatory process surrounding the gallbladder. 2 3 ASGBI SURGERY ASGBI SURGERY Paper 9 Paper 9 June 2021 June 2021 The patient was resuscitated with intravenous fluids and broad spectrum antibiotics. An indwelling doubt and the high perioperative risk, we decided to plan for all possibilities. Therefore, due to concerns catheter was placed to monitor urine output. Prothrombin complex concentrate was administered to regarding the gallbladder, we opted for a midline laparotomy and not for an inguinal approach. revert the Edoxaban effects. Conclusion To inform an open discussion about the risks of surgery, surgical risk scores were calculated. Nation- al Emergency Laparotomy Audit (NELA) and National Surgery Quality Improvement Project (NSQIP) This case presents a rare cause of SBO secondary to perforated cholecystitis in the presence of dual scores showed a risk of 40% and 58.5% for perioperative mortality, respectively. These high risks pathology and falsely reassuring imaging. It highlights some of the challenges and pitfalls associated where discussed with the patient and his family. Given the CT findings and the associated biochemical with emergency surgical care. abnormalities detected, the possibility of strangulated/ischemic bowel within the inguinal hernia existed and, therefore, the decision to immediately proceed to surgery was taken. References A midline laparotomy was performed as the quickest way to address both the hernia and the concern 1. Rami Reddy SR, Cappell MS. A Systematic Review of the Clinical Presentation, Diagnosis, and about the appearances in the RUQ in this very high risk patient. Diagnostic laparoscopy was briefly Treatment of Small Bowel Obstruction. Curr Gastroenterol Rep 2017;19:1–14. https://doi.org/10.1007/ considered but ultimately not performed due to significant abdominal distension and the need for ex- s11894-017-0566-9. pediency. 2. Kwok AMF, Attwell-Heap A. Acute necrotizing cholecystitis as a rare cause of mechanical small bowel Findings were of a perforated gallbladder with associated sub hepatic and pericholecystic abscess, obstruction. ANZ J Surg 2020;90:385–7. https://doi.org/10.1111/ans.15168. with omentum and small bowel trapped into the inflammatory process causing mechanical SBO. The abscess cavity was drained and the small bowel mobilised. No bowel resection was necessary. A sub- 3. Bakshi C, Ruff S, Caliendo F, Agnew J. Acute cholecystitis in a parastomal hernia causing a small bow- total cholecystectomy was performed, which revealed an obstructing calculus in the gallbladder neck. el obstruction. J Surg Case Reports 2017;2017:rjx235. https://doi.org/10.1093/jscr/rjx235. The cystic duct was ligated to avoid a bile leak. The right inguinal hernia was incidental, likely longstanding and containing viable small bowel. The hernia was reduced and the defect repaired with- 4. Khan A, Flavin KE, Harris LS, Chaudhry MN, Reading N. Bowel hath no fury like a out a mesh due to the intra-abdominal infection. gallbladder inflamed. J Surg Case Reports 2014;2014. https://doi.org/10.1093/jscr/rju028. Post operatively, he was transferred to the intensive care unit since the patient needed support with vasopressors. On the fourth post-operative day the patient was stepped down to the ward, and dis- charged home on the 12th post-operative day. Histopathology of the gallbladder confirmed acute calculous cholecystitis with an area of perforation. Discussion The most common causes of SBO are adhesions and hernias1. Obstruction secondary to perforated gallbladder is a rare phenomenon. After reviewing the literature for aetiologies of SBO related to acute cholecystitis, only three case reports were retrieved. Kwok et al reported a SBO due to acute cholecys- titis2. In this case, an inflammatory phlegmon secondary to cholecystitis was adherent to an ileo-ceacal anastomosis from a previous right hemicolectomy. Bakshi et al described acute cholecystitis within a parastomal hernia, which contributed to mechanical SBO3, the precipitating factor being the herniation of the gallbladder into the hernia. Khan et al reported a large bowel obstruction at the hepatic flexure4 with concomitant acute cholecystitis and perforated gallbladder. The hypothesised pathophysiological process was that of acute cholecystitis leading to a paralytic ileus. In our case intraoperative findings suggested a mechanical obstruction secondary to adhesion of small bowel to the wall of an abscess secondary to gallbladder perforation related to acute cholecystitis, leading to an acute kink in the bowel and obstruction. This is an uncommon presentation. There are some important learning points. Always consider a range of differentials despite being presented with a potential overt diagnosis, in this instance an incarcerated inguinal hernia. Surgeons should review CT images themselves without reliance on reporting, as these can be misleading. Due to the patient arriving to our unit in the middle of the night, his poor overall condition and our hospital outsourcing the reporting of all radiology investigations out of hours, we did not have the time or opportunity to obtain a second opinion with regards to the RUQ findings. Rather, given the clinical 4 5.