Intrahepatic Rupture of Acute Cholecystitis Complicated by Septic Portal Thrombosis

Gallbladder rupture, though rare, is a serious complication often arising from choledocholithiasis and subsequent interventions such as endoscopic retrograde cholangiopancreatography (ERCP). In this case, the patient presented with acute choledocholithiasis and underwent ERCP with sphincterotomy and stone extraction, followed by placement of a fully covered metal stent in the common bile duct (CBD). While the use of covered stents is appropriate, it is important to note that these stents can obstruct the cystic duct orifice in patients with a gallbladder. This occurs in more than 33% of patients with a low cystic duct junction, leading to obstructive acute cholecystitis, as seen in patients with pancreatic ductal adenocarcinoma (PDAC) or distal cholangiocarcinoma who receive metal biliary stents. In this case, the patient developed a liver abscess following a gallbladder rupture, likely due to the stent obstructing the cystic duct. The liver abscess was managed with percutaneous drainage, and cultures grew Streptococcus anginosus, a common pathogen in hepatobiliary infections. The patient was treated with IV piperacillin-tazobactam, followed by oral amoxicillin-clavulanate for a 4-6 week course. Additionally, portal vein thrombosis, a known complication of severe infection, was identified and treated with anticoagulation. This case highlights the need for careful stent selection and possible prophylactic cholecystectomy in patients with a functioning gallbladder to prevent post-ERCP complications like cholecystitis and abscess formation. Early diagnosis, timely drainage, and appropriate antibiotic therapy are critical to managing such complex hepatobiliary conditions.