Reporte de Caso

Acalculous Cholecystitis and COVID-19. A Case Report

ACALCULOUS CHOLECYSTITIS AND COVID-19. A CASE

REPORT

Ana María Pérez Murcia1, Luisa Fernanda Amado2, Laura Camacho3

Abstract

Introduction. COVID-19 (Coronavirus disease 2019) is mainly characterized by its respiratory symp-
toms, but numerous clinical presentations have been described with a recent increment in gastrointesti-
nal manifestations. Presentation of the case. A 33-year-old, overweight man with no other known me-
dical history, consulted due to symptoms suggestive of biliary pathology and a system review finding
of cough and dyspnea. He was taken to surgery due to the finding of AC (Acalculous Cholecystitis)
and in the postoperative period, he presented respiratory distress, identifying positive SARS-CoV-2
(Severe Acute Respiratory Syndrome Coronavirus 2), previous idiopathic heart failure, and acute pul-
monary thrombosis. Discussion. The presentation of AC with SARS-CoV-2 is infrequent. It does not
have an established clinical pattern and there are multiple confounding factors that make it a diagnos-
tic challenge, and even a distracting factor for the diagnosis of COVID-19 and its complications.

Keywords: Acalculous Cholecystitis; COVID-19; SARS-CoV-2.

1. Servicio de Medicina Interna, Hospital de San José. Especialista Docencia Universitaria, Fundación Universitaria de Ciencias de
la Salud.
2. Servicio de Medicina Interna, Hospital de San José. Residente, Fundación Universitaria de Ciencias de la Salud.
3. Calidad, Médico Hospitalario. Hospital de San José.

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Ana María Pérez Murcia, Luisa Fernanda Amado, Laura Camacho

COLECISTITIS ACALCULOSA Y COVID-19. REPORTE DE CASO

Resumen

Introducción. La COVID-19 (del inglés Coronavirus disease 2019), se caracteriza principal-

mente por su sintomatología respiratoria, pero se han descrito numerosas formas de presen-
tación con un aumento reciente de las manifestaciones gastrointestinales. Presentación del
caso. Varón de 33 años con sobrepeso y sin otros antecedentes conocidos, que consulta
por sintomatología sugestiva de patología biliar y hallazgo a la revisión por sistemas de tos y
disnea. Es llevado a cirugía por hallazgo de CA (Colecistitis Acalculosa) y en el posoperatorio
presenta dificultad respiratoria identificando SARS-CoV-2 (del inglés severe acute respiratory
syndrome coronavirus 2) positivo, falla cardíaca idiopática previa y trombosis pulmonar agu-
da. Discusión. La presentación de CA con SARS-CoV-2 es infrecuente, no tiene un patrón
clínico establecido y sí múltiples factores de confusión que lo tornan en un reto diagnóstico
e incluso un factor de distracción para el diagnóstico de la COVID-19 y sus complicaciones.

Palabras clave: Colecistitis Acalculosa; COVID-19; SARS-CoV-2.

Introduction Clinical Case

To date, COVID-19 produced by the SARS-CoV-2, A 33-year-old, overweight man from Bogotá, with no
has reported more than 400 million confirmed cases known medical history and without SARS-CoV-2 va-
and more than 5 million deaths around the world ccination, consulted for 20 days of oppressive pain in
according to the latest data from the World Health the epigastrium radiating to the right hypochondrium,
Organization (1). Although its pathology is mainly intensity 7/10 and exacerbated by food intake, asso-
characterized by respiratory symptoms, numerous ciated with multiple emetic episodes of food content,
forms of presentation have been described, from mild increasing on the day of admission. With a system re-
cutaneous manifestations to severe hematological and view finding of an eight day dry cough and worsening
cardiac alterations, and other more unusual such as dyspnea with small exertion.
hepatobiliary involvement (2).
Upon physical examination, he presented normotensi-
AC, defined as a necro-inflammatory state of the gall- ve, normal respiratory rate, adequate ambient oxygen
bladder in the absence of cholelithiasis, occurs more saturation, afebrile, mild tachycardia without cardio-
prevalently in critically ill patients, and in those with pulmonary alterations, and soft abdomen with sen-
septic processes. Although AC is well known, it does sation of a painful mass in the right hypochondrium,
not have an established clinical pattern, but does have but without signs of peritoneal irritation. Paraclinical
multiple confounding factors that make it a diagnostic tests showed leukocytosis, direct hyperbilirubinemia,
challenge (3), as occurred in the following case. and an alanine aminotransferase-alkaline phosphatase

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 Acalculous Cholecystitis and COVID-19. A Case Report

(ALT/ AP) ratio of 0,56 suggestive of cholestasis, but polymerase chain reaction) for SARS-CoV-2 positive,
otherwise normal liver profile. The abdominal ultra- glycated hemoglobin in the range of diabetes, and ele-
sound showed a partially distended gallbladder, with vated troponin, D-dimer and lactate.
thickened walls (9.2 mm), but without endoluminal
defects. General Surgery suspected AC with inter- Computed Angio-Tomography of the chest corrobora-
mediate risk for choledocholithiasis and requested a ted thrombus and wedge infarction (Figure 2).
Magnetic Resonance Cholangiography that showed a
distended, stoneless gallbladder with thickened walls Management was given with fluids, full anticoagula-
(7 mm) and a diagnosis of AC and hepatomegaly (Fi- tion, dexamethasone after antiparasitic treatment, and
gure 1). a diagnostic plus evacuatory thoracentesis, which co-
rroborated transudate without malignancy or tubercu-
He was taken to surgery to perform a LapC (Laparos- losis.
copic Cholecystectomy) with intraoperative findings
of cholecystitis with thickened walls, perivesicular Gallbladder pathology showed velvety mucosa without
fluid, pericholecystic adhesions, biliary sludge, and the presence of stones or tumor-like lesions, with in-
congested brown liver. flammation, muscle hypertrophy, subepithelial histio-
cytes, Rokitansky sinuses, and serosal congestion.
During the immediate postoperative period, he presen-
ted desaturation and bi-basal rales, for which a chest He required hospitalization in the general ward with
X-ray was requested, showing cardiomegaly, wide- oxygen by nasal cannula at 2 liters per minute, and due
based pleural consolidation of the left upper lobe, to adequate evolution, he was discharged after 10 days
suggesting pulmonary infarction, with bilateral basal with anticoagulation, oxygen therapy and oral hypo-
pleural effusion, and RT-PCR (Reverse Transcription glycemic agents. Additionally, referral for evaluation

A B

Figure 1. Magnetic Resonance Cholangiography.

A. Axial view in T2. B. Sagittal view in T2. The arrows show the gallbladder with thickened walls, perivesicular fluid,
and no evidence of stones inside.

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Ana María Pérez Murcia, Luisa Fernanda Amado, Laura Camacho

A B

Figure 2. Computed angiotomography of the chest with contrast, axial view.

A. The red arrow shows the location of the central opacification defect, which corresponds to thrombi in the
segmental branch for the superior lingular segment. The blue arrow indicates a pleural-based wedge infarction in this
same segment.
B. The red arrow shows the location of the central opacification defect, which corresponds to thrombi in the
posterolateral segmental branch of the right lower lobe. The blue arrow shows right pleural effusion, and the yellow
arrow shows cardiomegaly.

by Cardiology due to cardiomegaly in a young patient, with previous congestive hepatomegaly secondary to
where studies concluded idiopathic heart disease with unknown idiopathic heart disease, which, because it is
reduced ejection fraction. The patient was then referred painful, can confuse the physician when interpreting
to a heart failure clinic, waiting for cardiac transplant. suggestive signs of acute hepatobiliary disorder.

Discussion AC represents approximately 10% of all cases of acute

cholecystitis and is associated with a high rate of mor-
This case report of a patient with AC and COVID-19, bi-mortality (3). Various pathological processes have
who started with abdominal symptoms prior to respi- been described that may contribute to its generation.
ratory symptoms, shows how not suspecting SARS- Visceral hypotension and hypoperfusion cause poor
CoV-2 in patients with predominant abdominal symp- and irregular capillary refill of the gallbladder wall, ge-
toms can delay timely management and diagnosis of nerating ischemia, which could explain a possible as-
its complications, as in this case, a pulmonary throm- sociation with COVID-19 if it occurs with sepsis (13).
botic event. The decrease in contractility of the gallbladder muscle
generates cholestasis, producing accumulation of bile
An increase in gastrointestinal symptoms has been and increased viscosity, which causes leakage, increa-
seen in patients with COVID-19 even before develo- sed intracholecystic pressure, distention, and increased
ping pulmonary manifestations (Table 1) (4-12). This wall tension. This compromises arterial, lymphatic,
is a difficult case since the presentation of AC with and venous flow, leaving it susceptible to infection,
SARS-CoV-2 is infrequent, and less so, in a patient gangrene, or total necrosis. Once AC is established, it

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 Acalculous Cholecystitis and COVID-19. A Case Report

Table 1. Gastrointestinal (GI) symptoms associated with COVID-19.

All GI Nausea (N)/

No. of Anorexia, Diarrhea, GI Pain,
Study Date Location symptoms, Vomit (V),
patients No. (%) No. (%) No. (%)
No. (%) No. (%)

January-
Shihua
February, Wuhan 1,141 183 (16)  180 (15,7) 134 (11,7) 68 (5,9) 45 (3,9)
et al (7)
2020

 Januar-
Pan et
February, Hubei 204  103 (50,5) 81 (39,7) 4 (1,9) 35 (7,1) 2 (0,9)
al (8)
2020

December,
30
Guan et 2019-Ja-
Chinese 1,099 97 (8,8) N/A  55 (5,0) 42 (3,8)  N/A 
al (9) nuary,
provinces 
2020

January
Jin et al
-February Zhejiang  651 74 (11,4) N/A 11(1,6) 53 (8,1) N/A 
(4)
2020

January-
Fang et N: 59 (29,4) 
February, Hubei 305  159 (79,1)  101 (50,2) 66 (22,4)  12 (6,0)
al (10) V: 32 (15,9)
2020

January  N: 24
Zhang et
-February, Hubei 140 55 (39,6)  17 (12,2) (17,3)  18 (12,9) 8(12,9)
al (11)
2020 V: 75,0)

55 (9,9)
Wang et January, N: 14 (10,1) 
Hubei 138  36 (26) 14 (10,1) 3 (2,2)
al(12) 2020 V: 5 (3,6)

allows the rapid proliferation of microorganisms, pre- Some publications have tried to demonstrate the rela-
dominantly Escherichia coli, Klebsiella, Bacteroides, Pro- tionship between AC and COVID-19. Yin et al. looked
teus, Pseudomonas, and Enterococcus faecalis (13,14). for RT-PCR in the biliary fluid, without detecting it,
ruling out that SARS-CoV-2 is eliminated through bile
The exact pathogenesis of AC in COVID-19 is not and considering that AC is a complication of SARS-
clear, but it is known that the intracellular entry of the CoV-2 (17). In contrast, Balaphas et al. confirmed the
virus occurs through interaction with the angiotensin- presence of virus, by RT-PCR in the gallbladder wall,
converting enzyme 2 receptor that is present in various despite the fact that histological analysis did not show
tissues- lungs, liver, gallbladder and bile ducts. When any gallbladder inflammation. The significance of this
SARS-CoV-2 binds, it causes endothelitis which gene- finding for the pathogenesis of COVID-19 remains to
rates thromboembolism in various organs, including be determined (18).
the gallbladder. (15,16)

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Ana María Pérez Murcia, Luisa Fernanda Amado, Laura Camacho

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