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Hemoperitoneum from Hemorrhagic Perforated Cholecystitis in a Patient with Acquired Deficiency of Factor VIII

Hemorrhagic cholecystitis is a rarely observed clinical condition. There are a number of possible causes of bleeding inside the gallbladder lumen, namely, traumas, tumors, coagulation disorders, and dialysis.1 This condition can also be associated with the gallbladder’s rupture and subsequent hemoperitoneum. The case described here concerns a patient suffering from perforated hemorrhagic cholecystitis with a coagulation disorder due to an acquired deficiency of factor VIII. A 79-year-old patient was admitted to our institution after the spontaneous bleeding of the abdominal wall despite the lack of traumas. After having been subject to embolization, the patient was hospitalized in the ward, where a factor VIII deficit was diagnosed. The first hypothesis was that of a potential paraneoplastic cause from an unknown primitive neoplasia. During the anamnesis, the patient reported a prior gastric resection for cancer, performed by a median laparotomy 15 years earlier. No anticoagulation or antiaggregation therapy was reported before admission to our hospital. After hematologic consultation, it was decided to treat the patient with an eptacog-alfa–based therapy administered according to the following scheme: 7 mg two times a day (every 12 hours). During hospital stay, an urgent CT was performed because of an acute right upper abdominal pain. The arterial phase of the contrast-enhanced CT scan showed a massively swollen gallbladder with active extravasation from a cystic artery branch at the level of the organ’s posterior wall. The presence of bile with a mix of blood and stones was found inside the gallbladder. Surrounding the organ and above the liver, the scan evidenced the presence of blood, suggesting the possibility of a gallbladder rupture (Fig. 1). At the clinical examination, the patient presented right upper abdominal pain with positive Murphy sign; vital parameters were stable, with a BP of 140/80 mmHg, and a heart rate of 85 bpm. Blood tests were performed five hours before the abdominal pain occurred, and hemoglobin was 12.1 g/dL. The arterial blood-gas test was performed, showing a drop in the levels of hemoglobin (9.2 g/dL). Based on the active bleeding evidenced by the CT, the patient’s coagulation deficit, and the presumed rupture of the gallbladder, it was then decided to proceed surgically with a cholecystectomy. A laparoscopic