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An Unusual Cause of Sepsis After Laparoscopic Cholecystectomy
Electronic Clinical Challenges and Images in GI Grace Elta and Robert J. Fontana, Section Editors
An Unusual Cause of Sepsis After Laparoscopic Cholecystectomy Jack Kian Ch’ng,* Shin Yi Ng,‡ and Brian K. P. Goh*,§ Departments of *General Surgery; ‡Anesthesiology, Singapore General Hospital, Singapore; and §Office of Clinical Sciences, Duke-NUS Graduate Medical School, Durham, North Carolina
Question: A 74-year-old man with diabetes mellitus was hospitalized 3 months ago at a community hospital with acute cholangitis secondary to common bile duct stones. He was treated with intravenous antibiotics and the stones were successfully retrieved via endoscopic retrograde cholangiopancreatography. He was discharged well and subsequently underwent an uneventful interval laparoscopic cholecystectomy 8 weeks later. He was discharged on postoperative day 3. He presented to our hospital 2 weeks postoperatively with a 2-day history of persistent fever, nausea, and vomiting. On admission, he was in septic shock. He was clinically jaundiced and abdominal examination demonstrated a tender right upper abdomen without guarding. Laboratory investigations demonstrated intravascular hemolysis (hemoglobin, 6.1 g/dL; spherocytosis; reticulocytosis; severely hemolysis serum; and unconjugated bilirubin, 354 mol/L) and acute renal impairment (serum urea, 29.1 mol/L; creatinine, 298 mol/L; hyperkalemia [K⫹, 5.7 mol/L], and metabolic acidosis [pH 7.23; PCO2, 19.8 mmHg; PO2 107.9; base excess, ⫺17.2 mol/L; standard bicarbonate, 11.2 mol/L]). Liver function tests were consistent with an acute hepatic injury (International Normalized Ratio, 2.12; prothrombin time, 22.0; serum aspartate aminotransferase, 4758 U/L; serum alanine transaminase, 1066 U/L; alkaline phosphatase, 144U/L; total bilirubin, 632 mol/L). Chest and abdominal radiography demonstrated an ovoid radiolucent lesion in the right upper quadrant suggestive of a gas-filled lesion in the liver (Figure A, B). This was confirmed on noncontrast computed tomography to be a liver abscess containing a large amount of gas with some fluid (Figure C). There was no evidence of pneumoperitoneum, free fluid or dilated bile ducts. Subsequent Doppler ultrasonography demonstrated normal perfusion of the liver with patent hepatic arteries, hepatic veins, and portal veins. There was no biliary dilatation. The patient underwent percutaneous drainage of the abscess and despite maximal supportive management in the intensive care unit including inotropic agents, broad-spectrum antibiotics, and renal replacement therapy, the patient rapidly deteriorated and he died within 36 hours after admission. What is your diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2012 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2012.05.040
GASTROENTEROLOGY 2012;143:e1– e2
Electronic Clinical Challenges and Images in GI, continued Answer to the Clinical Challenges and Images in GI Question: Image 1: C perfringens Septic Shock Fluid cultures from the abscess and blood cultures ultimately grew Clostridium perfringens. It is prudent to rule out underlying pathology of liver abscess after laparoscopic cholecystectomy such as retained stone (0.4%) biliary stricture, (0.5%) or hepatic vascular injury.1 In our patient, both ultrasonography and computed tomography did not demonstrate any retained stone or ductal dilatation suggestive of this. C perfringens infection can lead to various clinical diseases ranging from gastroenteritis, alimentary intoxication, gas gangrene, necrotizing enteritis, intravascular hemolysis, and septic shock.2 It is a rare but lethal infection known to cause massive intravascular hemolysis.2 It is more common in immunocompromised patients such as patients with hematologic disorders, diabetes mellitus, or malignancy.2 The focus of infection is usually hepatobiliary, intestinal or gynecologic, and it commonly occurs after an invasive procedure.2 Patients with C perfringens septic shock have a reported mortality rate of 80% with a median time between admission and death of 8 hours.2 Early intravenous antibiotic and urgent removal of the source of infection by percutaneous or surgical drainage may provide the only chance of survival for the patients.2 Since the first case report in 1992 by Batge et al, 40 cases of C perfringens septicemia have been reported in the English literature.2 C perfringens is a gas-forming, gram-positive, rod-shaped, anaerobic, spore-forming bacteria, and is known to be a commensal in the gastrointestinal and genitourinary systems.3 It produces ␣-toxin, which damages the structural integrity of the cell, leading to tissue necrosis, gas gangrene, spherocytosis of red blood cells, and hemolysis.3 It takes ⱖ24 – 48 hours to isolate the bacteria from fluid and blood culture. This may not be useful because culture-based antibiotic treatment may delay treatment. The pathognomonic gram-stain characteristics of C perfringens—large, blunt-ended, boxcar-shaped, gram-positive rods without spores—may provide a rapid diagnosis.3 In our patient, Clostridium infection was suspected even before confirmatory cultures based on the clinical picture of severe sepsis associated with massive intravascular hemolysis and the gas-filled liver abscess. However, despite early percutaneous drainage of the abscess and appropriate antibiotic therapy which was initiated within 12 hours from admission, the patient succumbed to the disease. References 1. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:1073– 1078. 2. van Burderen CC, Bomers MK, Wesdorp E, et al. Clostridium perfringens septicaemia with massive intravascular haemolysis: a case report and review of the literature. Neth J Med 2010;68:343–346. 3. Baron EJ. Rapid identification of bacteria and yeast: summary of a national committee for clinical laboratory standards proposed guideline. Clin Infect Dis 2001;33:220 –225.
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An Unusual Cause of Sepsis After Laparoscopic Cholecystectomy Jack Kian Ch’ng,* Shin Yi Ng,‡ and Brian K. P. Goh*,§ Departments of *General Surgery; ‡Anesthesiology, Singapore General Hospital, Singapore; and §Office of Clinical Sciences, Duke-NUS Graduate Medical School, Durham, North Carolina
Question: A 74-year-old man with diabetes mellitus was hospitalized 3 months ago at a community hospital with acute cholangitis secondary to common bile duct stones. He was treated with intravenous antibiotics and the stones were successfully retrieved via endoscopic retrograde cholangiopancreatography. He was discharged well and subsequently underwent an uneventful interval laparoscopic cholecystectomy 8 weeks later. He was discharged on postoperative day 3. He presented to our hospital 2 weeks postoperatively with a 2-day history of persistent fever, nausea, and vomiting. On admission, he was in septic shock. He was clinically jaundiced and abdominal examination demonstrated a tender right upper abdomen without guarding. Laboratory investigations demonstrated intravascular hemolysis (hemoglobin, 6.1 g/dL; spherocytosis; reticulocytosis; severely hemolysis serum; and unconjugated bilirubin, 354 mol/L) and acute renal impairment (serum urea, 29.1 mol/L; creatinine, 298 mol/L; hyperkalemia [K⫹, 5.7 mol/L], and metabolic acidosis [pH 7.23; PCO2, 19.8 mmHg; PO2 107.9; base excess, ⫺17.2 mol/L; standard bicarbonate, 11.2 mol/L]). Liver function tests were consistent with an acute hepatic injury (International Normalized Ratio, 2.12; prothrombin time, 22.0; serum aspartate aminotransferase, 4758 U/L; serum alanine transaminase, 1066 U/L; alkaline phosphatase, 144U/L; total bilirubin, 632 mol/L). Chest and abdominal radiography demonstrated an ovoid radiolucent lesion in the right upper quadrant suggestive of a gas-filled lesion in the liver (Figure A, B). This was confirmed on noncontrast computed tomography to be a liver abscess containing a large amount of gas with some fluid (Figure C). There was no evidence of pneumoperitoneum, free fluid or dilated bile ducts. Subsequent Doppler ultrasonography demonstrated normal perfusion of the liver with patent hepatic arteries, hepatic veins, and portal veins. There was no biliary dilatation. The patient underwent percutaneous drainage of the abscess and despite maximal supportive management in the intensive care unit including inotropic agents, broad-spectrum antibiotics, and renal replacement therapy, the patient rapidly deteriorated and he died within 36 hours after admission. What is your diagnosis? See the GASTROENTEROLOGY web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Conflicts of interest: The authors disclose no conflicts. © 2012 by the AGA Institute 0016-5085/$36.00 http://dx.doi.org/10.1053/j.gastro.2012.05.040
GASTROENTEROLOGY 2012;143:e1– e2
Electronic Clinical Challenges and Images in GI, continued Answer to the Clinical Challenges and Images in GI Question: Image 1: C perfringens Septic Shock Fluid cultures from the abscess and blood cultures ultimately grew Clostridium perfringens. It is prudent to rule out underlying pathology of liver abscess after laparoscopic cholecystectomy such as retained stone (0.4%) biliary stricture, (0.5%) or hepatic vascular injury.1 In our patient, both ultrasonography and computed tomography did not demonstrate any retained stone or ductal dilatation suggestive of this. C perfringens infection can lead to various clinical diseases ranging from gastroenteritis, alimentary intoxication, gas gangrene, necrotizing enteritis, intravascular hemolysis, and septic shock.2 It is a rare but lethal infection known to cause massive intravascular hemolysis.2 It is more common in immunocompromised patients such as patients with hematologic disorders, diabetes mellitus, or malignancy.2 The focus of infection is usually hepatobiliary, intestinal or gynecologic, and it commonly occurs after an invasive procedure.2 Patients with C perfringens septic shock have a reported mortality rate of 80% with a median time between admission and death of 8 hours.2 Early intravenous antibiotic and urgent removal of the source of infection by percutaneous or surgical drainage may provide the only chance of survival for the patients.2 Since the first case report in 1992 by Batge et al, 40 cases of C perfringens septicemia have been reported in the English literature.2 C perfringens is a gas-forming, gram-positive, rod-shaped, anaerobic, spore-forming bacteria, and is known to be a commensal in the gastrointestinal and genitourinary systems.3 It produces ␣-toxin, which damages the structural integrity of the cell, leading to tissue necrosis, gas gangrene, spherocytosis of red blood cells, and hemolysis.3 It takes ⱖ24 – 48 hours to isolate the bacteria from fluid and blood culture. This may not be useful because culture-based antibiotic treatment may delay treatment. The pathognomonic gram-stain characteristics of C perfringens—large, blunt-ended, boxcar-shaped, gram-positive rods without spores—may provide a rapid diagnosis.3 In our patient, Clostridium infection was suspected even before confirmatory cultures based on the clinical picture of severe sepsis associated with massive intravascular hemolysis and the gas-filled liver abscess. However, despite early percutaneous drainage of the abscess and appropriate antibiotic therapy which was initiated within 12 hours from admission, the patient succumbed to the disease. References 1. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:1073– 1078. 2. van Burderen CC, Bomers MK, Wesdorp E, et al. Clostridium perfringens septicaemia with massive intravascular haemolysis: a case report and review of the literature. Neth J Med 2010;68:343–346. 3. Baron EJ. Rapid identification of bacteria and yeast: summary of a national committee for clinical laboratory standards proposed guideline. Clin Infect Dis 2001;33:220 –225.
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