Abdominal Wall Abscess in Acute Cholecystitis

Introduction

An abscess in the abdominal wall can occur for many reasons. One such reason is cholecystectomy (a surgery performed to remove stones in the gallbladder). Gallstones are hard deposits of bile, a digestive enzyme made by the liver. Gallbladder perforation, a complication of acute cholecystitis, can also show an abdominal wall abscess. Patients with this condition should seek help immediately because it can be life-threatening.

What Is an Abdominal Wall Abscess?

An abscess is a collection of pus (fluid) in an area due to infection. An abscess on the abdominal wall is called an "abdominal wall abscess" and is seen in an unusual condition called cholecystitis and gallbladder perforations. An abdominal wall abscess occurs mainly due to the following:

• The digestive tract's bacteria.

• After cholecystectomy (a surgery performed to treat acute cholecystitis).

What Is Acute Cholecystitis?

Acute cholecystitis is an inflammation of the gallbladder, an organ that helps digest food, located just below the liver. It is caused by the blocked tube connecting the gall bladder and the liver. Due to the blockage, digestive juice called bile, secreted by the liver, is trapped in the gallbladder, building up pressure and causing inflammation.

Based on the cause, acute cholecystitis can be classified into two types:

• Calculus Cholecystitis (Due to the Formation of Gallstones): It is the most common type but not severe. As the gallstones block the duct, a buildup of pressure in the gallbladder causes inflammation. The inflamed gallbladder can get infected.

• Acalculous Cholecystitis (Caused Due to Accidental Trauma): It is less common but severe. It can be caused due to accidental trauma while performing other surgery or due to burns, sepsis (chemicals released into the bloodstream), and HIV (human immunodeficiency virus).

How Is Acute Cholecystitis Treated?

• At the beginning of the treatment, the patient will be asked to fast (not to eat or drink) to reduce stress on the gallbladder.

• Receive fluids through IV (intravenously) to avoid dehydration.

• Pain-relieving medications are given parallel to antibiotics (medicines to treat infections). According to the advice of a general physician, the patient may need to stay longer in the hospital or get discharged depending on their overall health status.

• The initial treatment may help ease certain cases, with the advice for cholecystectomy (surgery to remove the gallbladder) when it does not.

It is of three types:

• Laparoscopic Cholecystectomy: The gallbladder is removed using special instruments through the abdomen.

• Single-Incision Laparoscopic Cholecystectomy: Only one cut is made to carry out the process.

• Open Cholecystectomy: A single large cut is made to carry out the process. Percutaneous cholecystectomy can also be performed when cholecystectomy cannot be carried out. In percutaneous cholecystostomy, a needle is inserted into the abdomen to drain the fluid buildup in the gallbladder.

What Causes Abdominal Wall Abscess in Acute Cholecystitis?

An abdominal wall abscess in acute cholecystitis is reported to occur after cholecystectomy when the gallstones have not been removed completely. For example, gallstones may be broken during surgery but cannot be completely removed. In such conditions, an infection can begin, leading to an abscess.

What Are the Symptoms of an Abdominal Wall Abscess in Acute Cholecystitis?

Following are the symptoms of an abdominal wall abscess in acute cholecystitis:

• Pain and inflammation in the area.

• There can be spontaneous or occasional drainage of pus.

• Uncharacteristic rectal pain.

• A feeling of heaviness in the rectal area.

• Unable to completely defecate.

• Fever.

• Lack of appetite.

• Yellowing of the skin (change in color of skin to yellow-jaundice).

What Is Gallbladder Perforation?

It is a complication of acute cholecystitis in which the gallbladder splits open inside the abdomen, causing a pus-filled abscess.

What Causes Gallbladder Perforation?

It is caused by a gallstone blocking the cystic duct, which causes a rise in pressure, which degrades the membrane, and causes an abscess.

There are three types of gall bladder perforations:

• Type 1 (Acute): Generalized Biliary Peritonitis - Inflammation of the abdominal wall lining.

• Type 2 (Subacute): Fluid Collection - Localized fluid collection at the site, leading to abscess formation.

• Type 3 (Chronic): Internal and External Fistula - An abnormal passage between organs or between the organ and the body surface.

When Should You Seek Help?

Usually, symptoms manifest in milder forms and progress severely. However, as it is a progressively life-threatening disease, one must seek help immediately.

How Is Abdominal Wall Abscess in Acute Cholecystitis Diagnosed?

Diagnosis of the condition can be done in the following ways -

• Computed tomography(CT scan) is performed to visualize the internal anatomy digitally.

• A cavity, along with any remnants of gallstones after the cholecystectomy, can be visualized.

• Laboratory tests report.

• Infection with increased levels of c-reactive protein (checks for inflammation in the body) and increased white blood cells (cells helping the body fight against infections).

What Is the Treatment for Abdominal Wall Abscess in Acute Cholecystitis?

Under anesthesia, wound exploration and drainage of the abscess are performed. Antibiotic treatment is given for 14 days and discharged after nine days from surgery. In general, treatment of abdominal wall abscess may include:

• Cholecystectomy (a surgical procedure in which the entire gall bladder is removed).

• Drainage of the abscess (draining the contents of the abscess such as pus, blood other fluid, and debris).

• Gastric lavage (administration and evacuation of small amounts of liquid through a tube to remove toxic substances).

How Can Abdominal Wall Abscess in Acute Cholecystitis Be Prevented?

Prevention of abdominal wall abscess in acute cholecystitis can be prevented by the following ways:

• Removal of almost all the stones.

• Dilution of the bile salts through copious irrigation.

• Use an endo bag if gallstones remain.

• If there is a perforation, immediately use a suction device to extract as much gallbladder content as possible.

• Suspected lost gallstones should be documented in the report.

• Post-operative care.

Conclusion

An abdominal wall abscess in acute cholecystitis is a serious condition that needs immediate attention when the symptoms show up. Proper precautions and retrieval of all the gallstones during the cholecystectomy can help prevent abscesses. If any of the symptoms mentioned above are experienced, seek medical advice and follow the proper treatment protocol. Early treatment of life-threatening conditions, such as abdominal wall abscesses in acute cholecystitis, is always the best option.