The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–3, 2017
Ó 2016 Elsevier Inc. All rights reserved.
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2016.12.016

Clinical
Communications: Adult

PERIHEPATIC, PULMONARY, AND RENAL ABSCESSES

DUE TO SPILLED GALLSTONES

Jacob Lentz, MD,* Maria A. Tobar, BA, BS,† and Caleb P. Canders, MD*
*Department of Emergency Medicine, UCLA Medical Center, Los Angeles, California and †The David Geffen School of Medicine at UCLA,
Los Angeles, California
Reprint Address: Caleb P. Canders, MD, Department of Emergency Medicine, David Geffen School of Medicine at UCLA, 924 Westwood Boulevard,
Suite 300, Box 951777, Los Angeles, California 90095-1777

, Abstract—Background: Spilled gallstones are common
during laparoscopic cholecystectomy; however, they rarely
lead to postoperative complications. Perihepatic abscesses
develop in < 0.1% of patients with spilled gallstones and are
typically contained within the peritoneal cavity. Case Report:
We present a 57-year-old man with history of cholecystectomy
2 years prior who presented with cough and flank pain and was
discovered to have a perihepatic abscess invading his lung and
kidney secondary to a spilled gallstone. Why Should Emer-
gency Physicians Be Aware of This?: Although most perihe-
patic abscesses can be treated with percutaneous drainage
and antibiotics, abscesses secondary to spilled gallstones usu-
ally require open or laparoscopic surgery to drain the abscess
and retrieve the gallstone. Prompt identification of spilled gall-
stones in patients with intra-abdominal and intrathoracic ab-
scesses can thereby guide disposition and decrease morbidity
and mortality. Ó 2016 Elsevier Inc. All rights reserved.
reported 1–2% of total cholecystectomies result in
retained, spilled gallstones (1,2). Abscesses resulting
from spilled gallstones are uncommon and usually
occur within the first postoperative year and are limited
to the abdomen (1). We present a 57-year old man with
history of laparoscopic cholecystectomy 2 years prior
who presented with cough and flank pain and was discov-
ered to have a perihepatic abscess invading his thorax and
kidney. The abscess failed to resolve with percutaneous
drainage and antibiotics. Open thoracotomy revealed
spilled gallstones as the nidus of infection. Emergency
physicians should consider delayed development of an
intra-abdominal or -thoracic abscess secondary to spilled
gallstones in the differential diagnosis of patients with the
appropriate surgical history.

, Keywords—perihepatic abscess; pulmonary abscess; CASE REPORT

renal abscess; spilled gallstone; laparoscopic cholecystectomy
complications
INTRODUCTION
Gallbladder perforation is common during laparoscopic
cholecystectomy and results in spilled gallstones in up
to 10% of cases (1–4). Surgeons typically attempt to
retrieve spilled gallstones intraoperatively, however, a
A 57-year-old man with history of diabetes presented
with 2 weeks of intermittent, sharp, right flank pain that
radiated to his right shoulder and was worse with
movement. He also reported 2 weeks of pleuritic, right-
sided chest pain associated with a dry cough and painless
hematuria. He denied hemoptysis, night sweats, fevers,
chills, weight loss, shortness of breath, dyspnea on
exertion, dysuria, or urinary frequency. Surgical history
was notable for cholecystectomy 2 years prior. He was
afebrile with a pulse of 110 beats/min, blood pressure

RECEIVED: 25 July 2016; FINAL SUBMISSION RECEIVED: 21 December 2016;

ACCEPTED: 22 December 2016

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2 J. Lentz et al.

of 170/80 mm Hg, respiratory rate of 22 breaths/min, and

oxygen saturation of 99% on room air. Examination was
notable for sinus tachycardia, decreased breath sounds on
the right, and tenderness to palpation of his right chest
wall and right costovertebral angle.
Blood tests were notable for: hemoglobin 10.2 g/dL
(normal 11.2–16.0 g/DL), white blood cell count
14.4  103 cells/mm3 (normal 3.8–10.9  103 cells/mm3)
with 83% neutrophils, and platelet count 450,000 cells/
mL (normal 141,000–401,000 cells/mL). Results from a
comprehensive metabolic panel and coagulation studies
were normal. Urinalysis showed numerous red blood cells.
A chest x-ray study revealed right lower and middle lobe
opacifications (Figure 1). A contrast-enhanced computed
tomography scan of the chest, abdomen, and pelvis showed
a perihepatic abscess with local invasion into the right
kidney and lung (Figure 2).
The patient received intravenous fluids and broad-
spectrum antibiotics. Interventional radiology and cardio-
thoracic surgery were consulted to discuss drainage, and
the patient was admitted to the medical intensive care
unit for close monitoring. Interventional radiology-
guided drainage failed to resolve the abscess and the
Figure 2. Contrast-enhanced computed tomography reveals a
patient subsequently underwent open thoracic drainage. loculated cystic structure surrounding the liver (white star) with
Intraoperatively, the patient was discovered to have multi- invasion into the right renal capsule (black arrow) and through
ple, spilled gallstones from his prior cholecystectomy in the diaphragm into the right pleural cavity (white arrow).
the perihepatic abscess cavity. Cultures of the abscess
grew Klebsiella pneumonia. gallstones rarely lead to complications, and < 0.1% of
patients with spilled gallstones develop postoperative
DISCUSSION abscesses (5). Abscess formation is likely to occur in
older patients and patients who have acute cholecystitis
Iatrogenic gallbladder perforation occurs in 10–40% of at the time of surgery. Literature on intrathoracic and
laparoscopic cholecystectomies and results in retained, renal complications of spilled gallstones after laparo-
spilled gallstones in 1–2% of cases (1–4). Spilled scopic cholecystectomy is scarce. Pulmonary abscess,
empyema, broncholithiasis, cholelithoptysis, and peri-
nephric abscess have all been reported secondary to
spilled gallstones (6–9). Intra-abdominal and -thoracic
abscesses secondary to spilled gallstones typically
develop in the first year after cholecystectomy; however,
delayed abscess formation has been reported up to
15 years after cholecystectomy (10).
Perihepatic abscesses, although rare overall, can be life
threatening (11). In addition to spilled gallstones, perihe-
patic abscesses have been reported as a complication of
biliary tract disease (the most common etiology), appen-
dicitis, hematogenous or local spread from other intra-
abdominal infections, spilled appendicoliths, and retained
surgical sponges (12,13). Perihepatic abscesses can
extend into the right perinephric space and pleural
cavity by direct invasion or via lymphatic channels that
span the diaphragm. Escherichia coli and Klebsiella
pneumoniae are the two most common bacteria
Figure 1. A chest x-ray study reveals right lower and middle identified in cultures from perihepatic abscesses (13).
lobe opacifications (black star). Most perihepatic abscesses are small and can be treated

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Perihepatic, Pulmonary, and Renal Abscesses Due to Spilled Gallstones
with percutaneous drainage and broad-spectrum antibi-
otics, such as a beta-lactam/beta-lactamase inhibitor,
second-generation cephalosporin, or carbapenem. Perihe-
patic abscesses that are large, multi-loculated, or due to
spilled gallstones usually require open or laparoscopic
surgical drainage for more extensive drainage or removal
of the offending nidus (14).
WHY SHOULD AN EMERGENCY PHYSICIAN BE
AWARE OF THIS?
Emergency physicians should consider spilled gallstones as
the nidus for infection in patients with the appropriate surgi-
cal history presenting with intra-abdominal or intrathoracic
abscesses or with persistent or recurrent symptoms that fail
to improve with antibiotics or percutaneous drainage. Iden-
tification of spilled gallstones is important, as perihepatic
abscess can be invasive and potentially fatal, and surgical
intervention is frequently required to remove the gallstones.
REFERENCES
1. Woodfield JC, Rodgers M, Windsor JA. Peritoneal gallstones
following laparoscopic cholecystectomy: incidence, complications
and management. Surg Endosc 2004;18:1200–7.
2. Diez J, Arozamena C, Guiterrez L, et al. Lost stones during laparo-
scopic cholecystectomy. HPB Surg 1998;11:105–8.
Downloaded from ClinicalKey.com at Universitas Kristen Duta Wacana March 15, 2017.
For personal use only. No other uses without permission. Copyright ©2017. Elsevier Inc. All rights reserved.
3
3. Memon MA, Deeik RK, Maffi TR, et al. The outcome of unre-
trieved gallstones in the peritoneal cavity during laparoscopic
cholecystectomy: a prospective analysis. Surg Endosc 1999;13:
848–57.
4. Dobradin A, Jugmohan S, Dabul L. Gallstone-related abdominal ab-
scess 8 years after laparoscopic cholecystectomy. JSLS 2013;17:
139–42.
5. Schafer M, Suter C, Klaiber C, et al. Spilled gallstones after laparo-
scopic cholecystectomy. A relevant problem? A retrospective anal-
ysis of 10,174 laparoscopic cholecystectomies. Surg Endosc 1998;
12:305–9.
6. Robinson JR, Wright JK, Geevarghese SK. Dropped gallstones
causing a perihepatic abscess and empyema. Case Rep Surg 2015;
2015:629–704.
7. Papasavas PK, Caushaj PF, Gagne DJ. Spilled gallstones after lapa-
roscopic cholecystectomy. J Laparoendosc Adv Tech A 2002;12:
383–6.
8. Iannitti DA, Varker KA, Zaydfudim V, et al. Subphrenic and pleural
abscess due to spilled gallstones. JSLS 2006;10:101–4.
9. Hochhegger B, Zanetti G, Marchiori E. A huge transdiaphragmatic
abscess detected postcholecystectomy. Ann Thorac Surg 2012;93:
e163.
10. Arishi AR, Rabie ME, Hussain Khan MS, et al. Spilled gallstones:
the source of an enigma. JSLS 2008;12:321–5.
11. Hope WW, Vrochides DV, Newcomb WL, et al. Optimal treatment
of hepatic abscesses. Am Surg 2008;74:178–82.
12. Maatouk M, Bunni J, Schuijtvlot M. Perihepatic abscess secondary
to retained appendicolith: a rare complication managed laparos-
copically. J Surg Case Rep 2011;2011:6.
13. Lone GN, Bhat AH, Tak MY, et al. Transdiaphragmatic migration of
forgotten gauze sponge: an unreported entity of lung abscess. Eur J
Cardiothorac Surg 2005;28:355–7.
14. Mueller PR, Simeone JF, Butch RJ, et al. Percutaneous drainage of
subphrenic abscess: a review of 62 patients. AJR Am J Roentgenol
1986;147:1237–40.