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Case Report
Volume 3, Number 1, March 2018, pages 20-23
Delayed Presentation of Actinomycotic Intra-Abdominal Abscess Following Laparoscopic Cholecystectomy Complicated by Empyema: Dropped Gallstone to Blame?
Saptarshi Biswasa, c, Shekhar Gognab, Prem Patelb
aDepartment of Trauma and Acute Care Surgery, Forbes Hospital, Allegheny Health Network, PA, USA
bDepartment of General Surgery, Westchester University Medical Center, Valhalla, NY, USA
cCorresponding Author: Saptarshi Biswas, Department of Trauma and Acute Care Surgery, Forbes Hospital, Allegheny Health Network, PA, USA
Manuscript submitted November 10, 2017, accepted December 15, 2017
Short title: Actinomycotic Intra-Abdominal Abscess
doi: https://doi.org/10.14740/cii74e
| Abstract | ▴Top |
Laparoscopic cholecystectomy (LC) has universally become the gold standard for symptomatic gallstone disease. However, there are two specific complications more frequent in LC compared to open cholecystectomy, i.e. injury to the common bile duct and complications from dropped gallstones. Although asymptomatic in majority of cases, adverse events are reported in between 0.08% and 0.3% of these cases. The complications due to dropped stones include abscesses around liver, spleen, diaphragm, retroperitoneum and port sites, broncholithiasis, empyema, peritonitis leading to septicemia, intestinal obstruction, thrombosis of middle colic vein, colocutaneous fistula, and bladder obstruction. Abscesses are the most common infective complications and have been reported to occur from 3.3 months to 10 years. In most cases, E. coli have been identified in abscesses and in cause of septicemia and peritonitis. There are case reports of Klebsiella, Strep. bovis and Samonella being the contaminants after dropped stones. However, actinomycosis as source of infection has rarely been described. We describe a case of an elderly patient who presented with symptoms of shortness of breath and shoulder pain, 2.5 years after cholecystectomy, in whom actinomyces species were cultured from abdominal abscesses. Only few case reports, to our knowledge, have identified actinomyces species as an etiologic agent. We also briefly describe the management of such stones.
Keywords: Actinomycotic intra-abdominal abscess; Laparoscopic cholecystectomy; Empyema; Dropped gallstone
| Introduction | ▴Top |
Laparoscopic cholecystectomy (LC) is now the gold standard for symptomatic gallstone disease. It is a safe procedure in experienced hands. Major complications are bleeding, abscess, bile leak, biliary injury, and bowel injury in order of decreasing frequency [1].
There are two specific complications more frequent in LC than open cholecystectomy, i.e. injury to the common bile duct (CBD) and complications from dropped gallstones [2]. Incidence of dropped gallstones is approximately 7% in LCs [3]. In majority of the cases, these stones cause no harm; however, adverse events are reported in between 0.08% and 0.3% of these cases. The complications due to dropped stones have a very broad spectrum, including abscesses around liver, spleen, diaphragm, retroperitoneum and port sites, broncholithiasis, empyema, peritonitis leading to septicemia, intestinal obstruction, thrombosis of middle colic vein, colocutaneous fistula, and bladder obstruction [4, 5]. In most cases, E. coli have been identified in abscesses and in cause of septicemia and peritonitis [6].
We describe a case of an elderly patient who presented to the emergency department with symptoms of shortness of breath and right shoulder pain, a significant time after cholecystectomy, in whom actinomyces species were cultured from abdominal abscesses. Only very few case reports, to our knowledge, have identified actinomyces species as an etiologic agent. This article will also briefly describe the management of these stones.
| Case Report | ▴Top |
We present a case of a 79-year-old gentleman with a history of atrial fibrillation, coronary artery disease, colon cancer and spinal stenosis seen in clinic for recurrent gallstone pancreatitis. His pancreatitis resolved with appropriate conservative treatment. He underwent endoscopic retrograde cholangiopancreatography (ERCP) for presumed CBD stone/sludge. Sphincterotomy was performed and the patient tolerated the procedure well.
The following day, he was taken to the operating room for planned LC. Patient was noted to have 20 - 25 cc of bile tinged fluid in right upper quadrant around duodenum. This was felt to be from a duodenal perforation from his ERCP. Procedure was then converted to open cholecystectomy. The gallbladder was dissected out and removed and the abdomen was irrigated with copious amounts of normal saline. Duodenum was kocherized and a small perforation was found on the medial aspect of the duodenum. Abdomen was closed and two drains were placed. His postoperative course was uncomplicated and he was discharged on ninth postoperative day.
He developed recurrent intermittent, acute pain in upper abdomen associated with nausea. On admission, his liver function tests (LFTs) were elevated: AST 542, ALT 243, and ALP 352. He was started on empiric broad spectrum antibiotics. ERCP was performed on second hospital day. ERCP demonstrated dilated CBD with multiple stones. He tolerated procedure well. He was discharged to home next day in stable condition and his LFTs improved on subsequent follow-up.
The patient then represented to the emergency department 2.5 years later with shortness of breath and right shoulder pain. CT angiogram showed no evidence of pulmonary emboli but revealed a lobulated right pleural effusion and suspected right subdiaphragmatic fluid collection of size 7.6 × 3.5 cm. He was admitted to the medicine service for IV antibiotics to treat right lower lobe pneumonia. A CT scan of the abdomen/pelvis was obtained to better characterize the subdiaphragmatic fluid collection. Figure 1 shows collection in right subdiaphragmatic space.
 Click for large image | Figure 1. Right subdiaphragmatic space collection. |
Thoracic surgery consult was obtained for drainage of pleural effusion. Chest tube was placed into right pleural cavity with drainage of 600 cc of serosanguineous fluid. Gram stain of this fluid was negative. Repeat chest CT couple of days later showed interval placement of the chest tube with decrease in the pleural effusion but with loculated portions of fluid. The subdiaphragmatic fluid collection was again re-demonstrated, and the size was 6.5 × 4 cm (Fig. 2).
 Click for large image | Figure 2. Right pleural chest tube to drain the effusion. |
Patient underwent video-assisted thoracoscopic surgery (VATS) evacuation of hemothorax and decortication. He tolerated the procedure well. Two days after the decortications, a 12-F pigtail was placed within the subdiaphragmatic fluid collection by IR. Green pus of 60 cc was initially drained (Fig. 3). This was sent for culture and sensitivity Gram stain returned gram positive branching rods consistent with actinomyces israeli.
 Click for large image | Figure 3. Placement of pigtail in right subdiaphragmatic collection. |
His symptom of shortness of breath improved significantly and his chest tubes were removed on fourth postoperative day. Third CT scan showed near resolution of right pleural effusion. The pigtail was also removed. His WBC count and temperature were normal at the time of discharge. He was discharged with a prolonged course of amoxicillin for 6 months. He was clinically doing well with stable vital signs and adequate pain control.
| Discussion | ▴Top |
Gallbladder is prone to perforation during grasping, traction, dissection, and extraction while doing LCs. The quality of the gallbladder wall is also a contributing factor to gallbladder perforation. Hydrops of gallbladder is the most common condition leading to intra-operative perforation [7]. Factors predictive of complications due to peritoneal gallstones include older age, male sex, acute cholecystitis, spillage of pigment stones, number (> 15) or size (> 1.5 cm) of the stones, and perihepatic localization of the spilled stones [7, 8]. In experimental rat models implanting sterile stones into the peritoneal cavity failed to increase morbidity after LC, while implantation of stones with colonized bile has been demonstrated to increase the risk of abscess formation [9]. Abscesses are the most common infective complications. They can develop intraperitoneally, in retroperitoneum, thoracic cavity or abdominal wall. Abscess formation from dropped stones after LC has been reported to occur from 3.3 months to 10 years [10, 11].
In humans, reports have shown that up to 80-90% of pigmented stones have bacterial contamination, and the most common organism is E. coli [6]. There are numerous case reports of Klebsiella, Strep. bovis and Samonella being the contaminants after dropped stones [12, 13]. However, actinomycosis as source of infection has rarely been described in a few case reports. Actinomyces are Gram positive, filamentous, non-sporing, and microaerophilic or obligate anaerobic bacteria. These bacteria normally colonize the flora of the oral cavity, genital tract, and upper gastrointestinal tract. They have a granulomatous inflammatory response causing pus production and abscess formation which is then followed by necrosis and extensive, reactive fibrosis [14]. The incidence of actinomyces is 1:300,000 [15].
The challenge with actinomycosis infection is delayed diagnosis, and it has a chronic indolent course. In most of the case reports and case series, we observed the same pattern. These case series all report biliary spillage or a lost stone at the time of surgery. In our case, patient developed actinomyces abscess after 2.5 years. The diagnosis is established by pathological sampling of the fluid. Radiological techniques, including CT scan or magnetic resonance imaging (MRI), may show findings suggestive of the actinomycosis. However, they are not specific for the diagnosis and negative imaging does not exclude diagnosis. Treatment involves source control followed by prolonged course of oral antibiotic for 6 - 12 weeks [16].
Management of spilled gallstones has evolved from leaving the stones in situ to make effort to retrieve them. Data and studies have been performed to create standardization of management of spilled stones recommending that conversion to open cholecystectomy is unnecessary [17]. Various techniques include use of endobag to retrieve gallbladder from ports, 30° telescopes to aid better visualization, pressure injection, copiously irrigating peritoneal cavity to reduce contamination and facilitate further stone removal and use of shuttle stone collectors [18]. However, most important aspect in the management of stone spillage and biliary spillage is documentation. As a part of standardization and to help in early diagnosis of potential complication, UK Healthcare Commission has advised that the risk and possible complications of spilled gallstones should be part of informed consent and if this does occur and the stones are not retrieved, the patient and their primary healthcare provider should be informed [19].
Conclusions
Clinicians should include intra-abdominal and intrathoracic complications due to spilled gallstones in their differential diagnoses in any patient with a history of LC, regardless of the time elapsed since surgery. Careful follow-up of any case complicated by stone spillage is warranted, as sequelae may not be restricted to the peritoneal cavity. Source control is recommended for the management of abscess resulting from dropped gallstones after cholecystectomy. Complications from spilled stones or bile should be part of informed consent. Patient and their primary care physician should be informed if spillage occurs.
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