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Image challenge: A rare cause of hemoperitoneum

How would you diagnose this 59-year-old man presenting with 24 hours of sudden worsening right upper quadrant pain?
A Rare Cause of Hemoperitoneum
A Rare Cause of Hemoperitoneum

Gastroenterology image challenge:

An otherwise well 59-year-old man presented with 24 hours of sudden worsening right upper quadrant pain on a background of 2 weeks of mild, self-limiting right upper quadrant pain. No fevers, jaundice, vomiting or bowel habit changes were reported. He had no previous surgical or medical history, and no known biliary disease in the past. On presentation, he was mildly tachycardic and hypotensive, which was responsive to fluid resuscitation. The abdomen was moderately distended and focally tender in the right upper quadrant and epigastrium. Blood tests revealed a hemoglobin of 105 g/L, C-reactive protein of 41 mg/L, and elevated white blood cell count of 11 × 109/L. His liver function tests, lipase, troponin, renal function, and electrolyte levels were otherwise unremarkable.
A CT scan of his abdomen revealed a large hematoma in the right upper quadrant and a further hematoma in the pelvis and surrounding the gallbladder suggestive of acute perforation. There were no CT features of acute cholecystitis. A 24-mm calculus was identified in the gallbladder neck with hyperdense intraluminal content within the gallbladder, possibly representing hemorrhage or sludge/debris (Figure A). A decrease in the hemoglobin to 89 g/L resulted in transfusion of 1 U of packed red blood cells. A CT angiogram of the abdomen and pelvis showed no evidence of acute bleeding. Given his stable clinical picture and lack of evidence of active bleeding, the decision was made not to proceed to embolization, and he was closely monitored in a high-acuity unit until the following morning, when he underwent an exploratory laparoscopy.
Intraoperatively, 2 L of blood were found in the abdominal cavity with 4 free floating gallstones (Figure BC). After evacuation of the hemoperitoneum and thorough exploration, no bleeding point was identified within the peritoneal cavity, and a perforation in the gallbladder, on the wall opposite to the Dieulafoy’s lesion (DL), was confirmed (Figure D). The patient underwent laparoscopic cholecystectomy and had an uneventful recovery postoperatively.
What was the underlying cause of this patient’s hemoperitoneum?
To find out the diagnosis, read the full case in Gastroenterology.