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Year : 2018  |  Volume : 11  |  Issue : 5  |  Page : 430-432  

Acute acalculous cholecystitis after transurethral resection of the prostate

1 Department of Urology, Urmia University of Medical Sciences, Urmia, Iran
2 Student Research Committee, Urmia University of Medical Sciences, Urmia, Iran

Date of Web Publication5-Sep-2018

Correspondence Address:
Sedra Mohammadi
Student Research Committee, Urmia University of Medical Sciences, Urmia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.MJDRDYPU_229_17

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A 61-year-old man presented with a history of 4-month progressive hematuria, frequency, urgency, urinary straining, and terminal dripping, and he was treated with transurethral resection of the prostate in Imam Khomeini Educational Hospital, Urmia, Iran, in August 2016. Four days later, he developed fever, abdominal tenderness, abnormal liver function, and loss of consciousness. Computed tomography scan showed all classical findings suggestive of acute acalculous cholecystitis (AAC). Laparoscopic cholecystectomy was performed. The result showed a distended gallbladder with thickened walls. As the patient presented in this report had no risk factors for acalculous cholecystitis, physicians should be aware of the possibility of AAC as a life-threatening event after transurethral resection of prostate.

Keywords: Acute acalculous cholecystitis, benign prostate hyperplasia, transurethral resection of prostate

How to cite this article:
Farshid S, Eghbal M, Abyar B, Dindarian S, Mohammadi S. Acute acalculous cholecystitis after transurethral resection of the prostate. Med J DY Patil Vidyapeeth 2018;11:430-2

How to cite this URL:
Farshid S, Eghbal M, Abyar B, Dindarian S, Mohammadi S. Acute acalculous cholecystitis after transurethral resection of the prostate. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2020 Nov 30];11:430-2. Available from: https://www.mjdrdypv.org/text.asp?2018/11/5/430/240377

  Introduction Top

Transurethral resection of the prostate (TURP) is the accepted standard of procedure for patients with symptomatic benign prostatic hyperplasia having a bladder outlet obstruction. This therapy is used for men with unsuccessful medical management and less-invasive prostatic surgical procedures.[1],[2] Although surgical treatment has become safer over the years and mortality of TURP has declined significantly, the complications can still be life-threatening.[2] Acute acalculous cholecystitis (AAC) is an acute inflammation of the gallbladder which is possible to occur without gallstones or evidence of cystic duct obstruction.[3] As expressed in our study, this inflammatory process is rarely caused by TURP. Therefore, we would like to represent this case to highlight the possibility of AAC after TURP procedure.

  Case Report Top

A 61-year-old man with a 4-month history of lower urinary tract symptoms presented to the Department of Urology, Imam Khomeini Educational Hospital, Urmia, Iran, in August 2016. The symptoms include progressive hematuria, frequency, urgency, urinary straining, and terminal dripping. He was treated by placement of a urethral catheter into the bladder and received medications for retention, but he had no improvement in his symptoms. He denied dysuria, fever, hesitancy, or increased nocturia. He did not mention any familial history of prostate cancer, spinal cord injury, or any other neurological disease. He also had not undergone any intra-abdominal operations. The only positive point in his past medical history was hypertension. The patient did not mention pain in the flanks or abdominal areas. He did not complain of nausea, vomiting, diarrhea, or constipation. He also did not have anorexia and dizziness. His clinical features revealed normal body temperature of 36.7°C, pulse rate of 90/min, and blood pressure of 130/80 mmHg. The abdomen was not distended and there was no evidence of tenderness. His genitourinary, rectal, and neurologic examination was normal. Digital rectal examination demonstrated an enlarged symmetric prostate with rubbery consistency without nodules. Ultrasonography showed that prostatic volume was 19.2 cc and cystoscopy revealed postvoid residual volume of 150–200 ml with the evidence of trabeculated bladder wall and prominent median lobe.

His hemoglobin level was 13.9 g/dl. In addition, he had white cell count of 10.4 × 109/L, (neutrophilia of 43.9%), platelet count of 221 × 109/L, serum urea of 43 mg/dl (normal range: 10–50 mg/dl), and serum creatinine level of 1.37 mg/dl (0.6–1.4 mg/dl). His prostate-specific antigen level was 3.06 ng/dl (<4 ng/dl). Urine culture and urinalysis were negative for infection. The diagnosis was benign prostate hypertrophy and, consequently, he was scheduled for TURP.

The patient was under spinal anesthesia during the operation. Postoperatively, he complained of generalized abdominal pain, nausea, constipation, and insomnia. On the 4th day after the operation, his physical examination demonstrated abdominal distension, absence of bowel sounds, abdominal dysfunction, tenderness, rebound tenderness, and severe jaundice along with fever and loss of consciousness (Glasgow Coma Scale score = 11). He had total bilirubin count of 12.76 mg/dl (0.1–1.3 mg/dl), direct bilirubin count of 6.01 mg/dl (<2 mg/dl), aspartate aminotransferase of 180 u/l (<37 IU/L), alanine transaminase of 67 u/L (<41 IU/L), alkaline phosphatase of 409 u/l (80–306 IU/L), Na + of 132 mEq/L, and K + of 3.7 mEq/L. Ultrasonography showed no changes in gallbladder, liver, and portal vein diameter. Intrahepatic and extrahepatic bile ducts were also normal and there was no evidence of nephrolithiasis or renal mass. Gastroenterology consultation suggested hepatobiliary iminodiacetic acid (HIDA) scan or magnetic resonance cholangiopancreatography (MRCP). Due to unavailability of HIDA scan, MRCP was performed, but gallbladder did not appear in the test. Evidences apparently showed that the patient had an inflammatory process in the gallbladder occurring after the TURP as shown in the computed tomography scan [Figure 1]. After diagnosing AAC, he underwent laparoscopic cholecystectomy which demonstrated distended gallbladder with thickened walls and no gallstones. After the operation, his consciousness and abdominal pain recovered, but nausea and vomiting lasted for several days. The patient experienced an acceptable recovery in a 3-month follow-up.
Figure 1: Computed tomography image of the abdomen showing acalculous cholecystitis and sludge in the gallbladder, pericholecystic fluid, inflammation of the surrounding fat tissue, and abdominal distention

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  Discussion Top

We present the case of a patient with AAC after TURP. Acalculous cholecystitis is a disease that mainly develops in critically ill patients. It usually occurs due to sepsis, trauma, burn, prolonged fasting, and in patients with systemic infections. It has been reported after different types of surgeries such as abdominal wall repair,[4] gastrointestinal surgery,[5] and laparoscopic appendectomy,[6] but not after TURP, especially in middle-aged people. The pathogenesis of AAC is still unclear. Some studies suggest that decrease of blood flow in posttraumatic patients and constriction of abdominal visceral vessels might be the reason of AAC.[7] Yet, the most common theory of AAC is bile stasis leading to change in combination and concentration of bile in the gallbladder contents, which results in obstruction and ischemia.[6],[8] Multiple factors such as dehydration, fasting, analgesia, anesthesia, and fever contribute to bile stasis.[8] It seems that the most possible mechanism of AAC in our patient was bile stasis due to spinal anesthesia during the operation and the narcotics given for the pain medication. Diagnosis of AAC is difficult due to nonspecific signs. Changes in the gallbladder contents are associated with high morbidity and mortality.[6] Hence, in case of delayed diagnosis, we should consider perforation and necrosis of the entire gallbladder. Lindberg et al. reported that postoperatively gallbladder may become a target for organisms present in the bloodstream.[9] The definitive treatment for AAC is cholecystectomy. Percutaneous cholecystostomy can also be performed due to the patient's condition.[6] Due to the patient's age and also the necessity of failure prevention in conservative management, we chose early cholecystectomy with spinal anesthesia as an effective therapy. Spinal anesthesia was selected instead of general anesthesia because of the patient's age and also in order to prevent postoperative complications.[10] According to our information, this is the first reported case of AAC occurred after TURP. Patients with AAC can develop necroinflammatory alterations, gangrene, and perforation of the gallbladder. Thus, when abnormal liver function, fever, leukocytosis, abdominal tenderness, and ileus are observed after surgery, physicians should be aware of the possibility of AAC as a life-threatening event after TURP.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Cattolica EV, Sidney S, Sadler MC. The safety of transurethral prostatectomy: A cohort study of mortality in 9,416 men. J Urol 1997;158:102-4.  Back to cited text no. 1
Crow P, Gilbert HW, Jones DJ, Ritchie AW. The influence of histological diagnosis on the postoperative complication rate following trans-urethral resection of prostate (TURP). Ann R Coll Surg Engl 2002;84:418-21.  Back to cited text no. 2
Barie PS, Fischer E, Eachempati SR. Acute acalculous cholecystitis. Curr Opin Crit Care. 1999;5:144.  Back to cited text no. 3
Reurings JC, Diaz RP, Penninga L, Nellensteijn DR. Acute acalculous cholecystitis after abdominal wall repair (Rives-Stoppa). BMJ Case Rep 2014;2014. pii: bcr2014203781.  Back to cited text no. 4
Crichlow L, Walcott-Sapp S, Major J, Jaffe B, Bellows CF. Acute acalculous cholecystitis after gastrointestinal surgery. Am Surg 2012;78:220-4.  Back to cited text no. 5
Kim KH, Kim JS, Nam SH, Kim KU, Kim WW, Kim YH, et al. Acute acalculous cholecystitis after laparoscopic appendectomy in a young healthy patient: Report of a case. Korean J Hepatobiliary Pancreat Surg 2013;17:83-5.  Back to cited text no. 6
Goldman G, Rafael AJ, Hanoch K. Acute acalculous cholecystitis due to an incarcerated epigastric hernia. Postgrad Med J 1985;61:1017-8.  Back to cited text no. 7
Ottinger LW. Acute cholecystitis as a postoperative complication. Ann Surg 1976;184:162-5.  Back to cited text no. 8
Lindberg EF, Grinnan GL, Smith L. Acalculous cholecystitis in Viet Nam casualties. Ann Surg 1970;171:152-7.  Back to cited text no. 9
Sinha R, Gurwara AK, Gupta SC. Laparoscopic surgery using spinal anesthesia. JSLS 2008;12:133-8.  Back to cited text no. 10


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