(Kiosk 1) Symptomatic Masquerade: A Case of Gangrenous Cholecystitis in a PICA Stroke

Case Diagnosis: Gangrenous cholecystitis

Case Description: 59-year-old male with history of hypertension, diabetes mellitus, and CVA presented with left-sided weakness, intractable hiccups, and nausea/vomiting. MRI brain showed diffusion restriction involving the left lateral medulla suspicious for PICA territory and inferior right occipital lobe infarcts. Patient appeared septic and was started on broad spectrum antibiotics; however, workup was inconclusive and no infectious source was identified with downtrending WBCs so antibiotics were terminated. Patient later endorsed left upper quadrant abdominal pain; abdominal x-ray showed large stool burden and repeat labs including LFTs, bilirubin, and WBCs were unremarkable. Bowel regimen was escalated with no resolution. WBC started uptrending and abdominal pain become more diffuse. CT abdomen with contrast was obtained, showing gangrenous cholecystitis with suspicion for focal perforation. Surgery was consulted and patient was scheduled for cholecystectomy. RUQ US showed biliary sludge and cholelithiasis and a possible contained perforated duodenal ulcer.

Discussion: Gangrenous cholecystitis is a serious complication of cholelithiasis with a greater mortality than noncomplicated cholelithiasis and can develop in 1-2% of patients with asymptomatic cholelithiasis annually. Vascular insufficiency causes epithelial injury secondary to persistent obstruction of the cystic duct, leading to significant inflammation and eventual necrosis. Associated disease risk factors include cardiovascular disease and diabetes. Findings may include elevated WBCs, AST, ALT, total bilirubin, pericholecystic fluid on ultrasound, and positive CT findings such as air or irregularities in the gallbladder wall, poor gallbladder wall enhancement, and pericholecystic abscess. In this case, labs were normal and the hiccups, nausea, and vomiting were attributed to the PICA stroke.

Setting: Inpatient Rehab Facility

Assessment/Results: Patient underwent a subtotal cholecystectomy. After the operation, hiccups resolved and abdominal pain improved.

Conclusion: While PICA strokes may present with hiccups, nausea, and vomiting, there should be a low threshold for pursuing further imaging despite normal lab values if there is clinical decline.