Acute Right Upper Abdominal Pain With No Trauma History

Question: An 82-year-old woman arrived in our emergency department for acute right upper abdominal pain with no trauma history. She had a medical history of cardiac arrhythmia (atrial fibrillation) with pacemaker insertion and anticoagulant therapy (warfarin 2.5 mg/d). At the time of her presentation Prothrombin time was 36.8 s, prothrombin activity was 21%, international normalized ratio was 3.32, and platelet count was normal (247 × 103/μL). There was no alteration in liver function tests. She underwent abdominal multiphasic contrast-enhanced multidetector computed tomography. The unenhanced phase demonstrated a distended gallbladder with slightly hyperdense heterogeneous material occupying all its lumen (Figure A). On the arterial phase (Figure B, arrowhead) it appeared inside the lumen of the gallbladder at the middle third of the inferior wall, a focal contrast media area, which become more evident on venous phase (Figure C, D, arrowhead). After multidisciplinary discussion and correction of coagulation parameters, the patient underwent laparoscopic cholecystectomy. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. This radiologic sign on multiphasic contrast-enhanced multidetector computed tomography with axial images (Figure A–C), coronal multiplanar reconstruction (Figure D) and coronal volume rendering technique were indicative for active hemorrhage of gallbladder wall. During the urgent surgical treatment there was confirmation of that distended gallbladder. Postoperatively opening of the gallbladder revealed in its lumen the presence of bile mixed with dishomogeneous blood clots. Pathologic evaluation demonstrated arteriosclerosis of cystic artery, with a pseudoaneurysmatic tear of one of its collateral branches with focal surround inflammatory tissue of gallbladder wall. The postoperative course was uneventful, and the patient was discharged on day 8. Hemorrhage from the gallbladder is not a frequent event.1Hudson P.B. Johnson P.P. Hemorrhage from the gall bladder.N Engl J Med. 1946; 234: 438-441Crossref PubMed Scopus (12) Google Scholar The etiologies for hemorrhage of the gallbladder are trauma, neoplasms, inflammation wall with gallstones, aneurysms, varicose veins with portal hypertension, arteriosclerosis, and coagulopathy. However, isolated gallbladder arterial hemorrhage owing to anticoagulation therapy has been reported rarely. This pathologic state can be detected by contrast-enhanced ultrasound, contrast-enhanced computed tomography, and digital subtraction angiography.2Krudy A.G. Doppman J.L. Bissonette M.B. et al.Hemobilia: computed tomographic diagnosis.Radiology. 1983; 148: 785-789Crossref PubMed Scopus (35) Google Scholar, 3Pandya R. O'Malley C. Hemorrhagic cholecystitis as a complication of anticoagulant therapy: role of CT in its diagnosis.Abdom Imaging. 2008; 33: 652-653Crossref PubMed Scopus (39) Google Scholar