Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome: A case report

INTRODUCTION: Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome (MS) is a complex surgical problem both diagnostically and in terms of management as it mimics both xanthogranulomatous cholecystitis (XGC) and gallbladder carcinoma. PRESENTATION OF CASE: A 48-year-old gentleman was referred to us with biliary colic and weight loss with ultrasound findings of gallstones. At subsequent follow-up he became deeply jaundiced with deranged liver function and a CT showing a gallbladder mass and dilated biliary tree. Follow-up MRCP suggested XGC and concomitant MS, but a malignant process could not be excluded. Pre-operative fine needle aspiration cytology (FNAC) at the time of percutaneous biliary drainage for his jaundice demonstrated XGC with no evidence of malignancy. Given the dense inflammation and a tense empyema at laparoscopy, he underwent a subtotal fenestrating cholecystectomy. The final histopathological diagnosis was acute cholecystitis. DISCUSSION: Our patient likely had unrecognised acute cholecystitis which progressed to a complex mass with empyema and type I Mirizzi Syndrome, ultimately resulting in severe obstructive jaundice mimicking gallbladder carcinoma. Given that a laparoscopic total cholecystectomy is dangerous in these cases of severe inflammation, a laparoscopic subtotal cholecystectomy has been shown to be a safe alternative to more invasive strategies and was successfully utilised in our patient. CONCLUSION: Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome is a rare manifestation that requires adequate pre-operative work-up to exclude malignancy. Subtotal fenestrating cholecystectomy is a safe and effective alternative to open surgery in these cases of complex inflammation. (C) 2020 The Author(s). Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY-NC-ND license (http://creative commons.org/licenses/by-nc-nd/4.0/).