P2177 - Acalculous Cholecystitis Secondary to an Acute on Chronic Hepatitis C Infection

Polina Gaisinskaya, MD¹, Mishah Azhar, MD², Michael Leary, MS², Christopher Gebara, MD^1
1Florida Atlantic University, Delray Beach, FL; ²Florida Atlantic University, Boca Raton, FL

Introduction: Acute acalculous cholecystitis (AAC), accounting for about 10% of cholecystitis cases, represents the inflammation of a gallbladder without evidence of gallstones. It usually results from gallbladder stasis and ischemia, which then causes a local inflammatory response within the wall. The condition is typically associated with critically ill patients as well as numerous other associated risk factors. There have been a few cases reported of AAC secondary to hepatitis infections. We present a case of a patient with acute on chronic hepatitis C (HCV) infection leading to ACC.

Case Description/Methods: A 27-year-old female with a past medical history of endometriosis, IV drug abuse, and untreated HCV presented to the emergency department with fever, chills, nausea, vomiting and right upper quadrant abdominal pain for 4 days. On admission, her labs were significant for an elevated total bilirubin 5.5, direct bilirubin 3.7, ALP 364, ALT 1739, and AST 1439. In the ED, an abdominal ultrasound (US) revealed an enlarged gallbladder with echogenic material, likely sludge. Abdominal CT scan revealed a normal liver, contracted gallbladder with 9 mm of wall thickening with a common bile duct of 4.6 mm. Her acetaminophen levels, drug screen, autoimmune panel and portal venous US ruled out any underlying liver pathology. Her subsequent MRI/MRCP revealed no evidence of stones, no intra/extrahepatic dilatation or pancreatic ductal dilation with marked thickening of the wall of the gallbladder the following day. Finally, her hepatobiliary iminodiacetic acid scan failed to visualize the gallbladder. Labs revealed positive HCV antibodies with a high RNA viral load. She was diagnosed in 2018 with HCV and never underwent treatment. She was managed conservatively with IV fluids and antibiotics, her lab abnormalities resolved and she was discharged after 6 days.

Discussion: Viral hepatitis is a very rare cause of AAC and the pathophysiology is not fully understood. Gallbladder wall thickening >4 mm with sludge on US, the modality of choice, is a typical finding associated with AAC. Elevation in the serum total bilirubin and alkaline phosphatase concentrations are not common in uncomplicated acute cholecystitis since obstruction is limited to the gallbladder. Previously, other viruses have been documented as a cause of AAC but HCV is not as common. Although not common, our case highlights the importance of screening for viral hepatitis when AAC is suspected with liver function test derangements.


Figure: CT scan of the patient’s abdomen revealed .99 cm thickening of the gallbladder wall on admission, consistent with gall bladder inflammation.


Disclosures:
Polina Gaisinskaya indicated no relevant financial relationships.
Mishah Azhar indicated no relevant financial relationships.
Michael Leary indicated no relevant financial relationships.
Christopher Gebara indicated no relevant financial relationships.


Polina Gaisinskaya, MD¹, Mishah Azhar, MD², Michael Leary, MS², Christopher Gebara, MD¹. P2177 - Acalculous Cholecystitis Secondary to an Acute on Chronic Hepatitis C Infection, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.