Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome: A case report

INTRODUCTION: Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome (MS) is a complex surgical problem both diagnostically and in terms of management as it mimics both xanthogranulomatous cholecystitis (XGC) and gallbladder carcinoma. PRESENTATION OF CASE: A 48-year-old gentleman was referred to us with biliary colic and weight loss with ultrasound findings of gallstones. At subsequent follow-up he became deeply jaundiced with deranged liver function and a CT showing a gallbladder mass and dilated biliary tree. Follow-up MRCP suggested XGC and concomitant MS, but a malignant process could not be excluded. Pre-operative fine needle aspiration cytology (FNAC) at the time of percutaneous biliary drainage for his jaundice demonstrated XGC with no evidence of malignancy. Given the dense inflammation and a tense empyema at laparoscopy, he underwent a subtotal fenestrating cholecystectomy. The final histopathological diagnosis was acute cholecystitis. DISCUSSION: Our patient likely had unrecognised acute cholecystitis which progressed to a complex mass with empyema and type I Mirizzi Syndrome, ultimately resulting in severe obstructive jaundice mimicking gallbladder carcinoma. Given that a laparoscopic total cholecystectomy is dangerous in these cases of severe inflammation, a laparoscopic subtotal cholecystectomy has been shown to be a safe alternative to more invasive strategies and was successfully utilised in our patient. CONCLUSION: Acute severe cholecystitis with empyema presenting as a gallbladder mass, jaundice and Mirizzi Syndrome is a rare manifestation that requires adequate pre-operative work-up to exclude malignancy. Subtotal fenestrating cholecystectomy is a safe and effective alternative to open surgery in these cases of complex inflammation.