An 81-year-old male patient with a history of hypertension, atrial fibrillation (for which he was on anticoagulant therapy) and prostate adenocarcinoma for which he had undergone surgery and was free of disease.
He came to the emergency room for an episode of precordial pain radiating to the right hypochondrium for several hours, accompanied by dyspnea on minimal exertion.
At the time of evaluation the symptoms had decreased.
Initially it was diagnosed as a possible acute coronary syndrome so treatment was initiated and an analytical was requested with enzymes of myocardial damage and an electrocardiogram without abnormalities.
The patient reported asthenia and discomfort in the right hypochondrium of 7 days of evolution, but at the time of evaluation she did not present pain and physical examination was anodyne so she was discharged from the cardiology department.
Six days later the patient came to the emergency department due to persistent pain in the right hypochondrium accompanied by nausea and hypoxia.
He had no fever or other accompanying symptoms.
Examination revealed a distended abdomen, tender to palpation in the right hypochondrium and flank with defense but with negative signs of Blumberg and Murphy.
Laboratory tests showed hemoglobin of 11 g/dl, hematocrit of 32.6%, leukocytes 14,000 with 74% neutrophils, INR 2.95 and fibrinogen 816 mg/dl.
An abdominal ultrasound was requested in which a gallbladder with ill-defined walls and gallstones was observed, in addition to a hypoechoic image compatible with perivesicular free fluid, interpreted as an acute computed tomography (CTfor study).
CT confirmed the presence of a gallbladder with ill-defined walls, together with a 7x3 cm high-density liquid that altered the surrounding fat compatible with perforated acute fat.
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The patient was stable and showed no signs of peritoneal irritation on examination, so it was decided to enter the surgical ward for conservative treatment.
Analgesic and antibiotic treatment (Piperacillin-Tazon) was established.
Forty-eight hours after admission, the patient continued to have right hypochondrium discomfort and leukocytosis persisted in the control analyses, so a control CT was performed.
The imaging test confirmed the poor evolution of the process with increase of the free intraabdominal fluid.
With these findings an urgent surgical intervention was performed.
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The patient underwent surgery through a right subcostal incision due to the peritoneal cavity.
An omentum plastron covering the gallbladder, with a tumoral aspect, with hemorrhagic suffusion in subphrenic and perirenal space was located, as well as hemoperitoneum point of hemorrhage 2.7 not appreciated.
A subtotal cholecystectomy was performed due to tumor invasion of the hepatic parenchyma and removed most of the omentum remaining macroscopic tumor recurrence.
The postoperative evolution was favorable and the patient was discharged on the 6 postoperative day.
One week after discharge, the patient was readmitted for abdominal pain in the right hypochondrium associated with asthenia and anorexia.
Analyses showed a hemoglobin of 7.5 g/dL, hematocrit of 22.7% and 32,500 leukocytes with left shift.
The patient had poor general condition, with pain in the mesogastrium and right hypochondrium.
Abdominal ultrasound showed a collection of 4x4 cm in the surgical bed.
Symptomatic treatment was established but the patient presented a progressive deterioration during the following days, marked by dyspnea, increased abdominal pain, melenas and a progressive anemization associated with hypotension despite transfusions and finally died at 20 days.
The study of the samples sent to pathology was carried out.
They identified areas with an infiltrate in intermingled cells with hemorrhagic foci and areas where the cells have vascular channels.
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The study was completed with an immunohistochemical analysis highlighting keratin 7 positive intense, D2.40, CD-31 and vimentin intensely positive.
All this is consistent with the diagnosis of primary epithelioid angiosarcoma of the gallbladder.
