Laparoscopic management of a painless perforative gangrenous cholecystitis after SARS-COV-2 infection

Abstract

INTRODUCTION. Acute cholecystitis (AC) is frequently encountered by the general surgeon and can naturally progress to gangrenous cholecystitis with perforation, affecting 2-36% of all patients with AC. This is the most severe form resulting from marked distention of the gallbladder, causing increased tension in the gallbladder wall. The associated inflammation leads to ischemic necrosis of the wall, with or without associated cystic artery thrombosis. Subsequent abscess formation and peritonitis can occur, increasing morbidity and mortality rates. The identified risk factors include diabetes mellitus, male sex, older age, critical illness, leukocytosis, elevated CRP levels and coronary heart disease.
CLINICAL CASE. We report a case of a 60-year-old male who presented in the emergency department with symptoms of sepsis and was diagnosed with a painless gallbladder perforation and formed perivesical and intrahepatic abscesses. The patient had been treated for SARS-CoV-2-associated infection 30 days prior. Therefore, we explore painless perforated gangrenous cholecystitis (GC) as a possible complication of COVID-19.
CONCLUSION. Sometimes, diagnosis and treatment of gangrenous cholecystitis can be challenging, especially when the pathology is related to microthrombosis and obliteration of the cystic artery leading to the painless clinical presentation. We suspect that a previous COVID-19 infection can induce a hypercoagulability state increasing the risk of thrombotic events which can have broad clinical manifestations in various tissues and organs. Gangrenous cholecystitis requires early accurate diagnosis and surgical treatment which reduces the postoperative complication rate. We suggest the laparoscopic method as a possible and safe option for treatment, as patients receive all the benefits of the minimally invasive approach.