Case Presentation :
Case History/ Examination: A 70-year-old female, referred to
our institution from a district hospital, presented with a month-long
history of nausea and vomiting immediately following ingestion of oral
liquids and semi-solids. Absent were complaints of abdominal pain or
fever. Known for schizophrenia under regular treatment for five years
and with a past medical history of treated filariasis in the left lower
limb four decades ago (Figure 1), she had no record of diabetes
mellitus, tuberculosis, or asthma, and no prior abdominal surgeries. A
physical examination revealed a soft, non-tender, non-distended abdomen
with a palpable, firm lump spanning from the right hypochondrium to the
right iliac fossa (RIF) (Figure 2).
Methods: Imaging studies, including ultrasound and
contrast-enhanced computer tomography (CECT) of the abdomen, indicated a
significant, lobulated, multiloculated cystic lesion measuring (19 x 5.8
x 3) cm and approximately 120 ml in volume (Figure 3 and 4).
This lesion was observed abutting the inferior and medial surfaces of
the liver, extending to the RIF region, with minimal fat stranding on
its anteromedial aspect, leading to a provisional diagnosis of a large
GB mucocele (Figure 3 and 4). Laboratory investigations were largely
unremarkable, with a total leukocyte count (TLC) of 15,000 cells/mm3 and
hemoglobin (Hb) levels at 10.9 g/dl. Initially scheduled for USG-guided
percutaneous pigtail drainage (cholecystostomy), deteriorating
hemodynamics necessitated an emergency laparotomy under general
anesthesia. Intraoperatively, a GB perforation approximately 11 cm in
size was discovered on the right lateral wall of the fundus, accompanied
by an organized intraperitoneal collection tracking inferiorly from the
GB along the right-sided greater omentum up to the RIF region (Figure 5
and 6). Surgical intervention included peritoneal lavage (Figure 7) with
adhesiolysis and a left-sided abdominal drain placement.
Conclusion and Result: Subsequently, the patient was
transferred to the ICU in an intubated state and remained on ventilatory
support until succumbing on post-operative day 3 (POD 3).