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New Delhi, September 16, 2021:
According to Prof. Anil Arora, Chairman, Institute of Liver, Gastroenterology and Pancreatobiiliry Sciences, Sir Ganga Ram Hospital, New Delhi, “We recently successfully treated five patients of gall bladder gangrene between June to August 2021, who had recovered from Covid-19 infection and presented with severe inflammation of gall bladder without gall stones (acalculous cholecystitis) resulting in gangrene of gall bladder requiring urgent surgery.
To the best of our knowledge this is the first report of series of five cases from India in which the gall bladder gangrene had occurred in patients after recovery from Covid-19 infection”.
Gall bladder stone disease is a very common problem in North India (8% of the general population) and is responsible for 90% cases of acute inflammation called cholecystitis. Only 10% of patients have non calculous inflammation of gall bladder called acalculous cholecystitis. After the second wave of the Covid-19, in April-May 2021, some COVIVD-19 infected patients presented with unusual manifestations which we described earlier as CMV colitis and liver abscesses.
Prof. Anil Arora added, these patients were of age group between 37-75 yrs and Four were males one was female. All patients had fever, pain in the right upper quadrant of abdomen and vomiting. Two of these patients had diabetes and one also had heart disease.Three patients received steroids for the management of Covid-19 symptoms. Median duration between Covid-19 symptoms and diagnosis of acalculous cholecystitis was two months. Diagnosis in these patients was confirmed using ultrasound and CT scan of abdomen which showed gall bladder wall edema and gangrene in all with concomitant gall bladder perforation in four patients. All these patients successfully underwent Laparoscopic removal of necrotic perforated gall bladders.
He also added that Acalculous cholecystitis with gangrenous gall balder is a serious condition associated with high morbidity upto 30 to 60% and much higher mortality than calculous cholecystitis and is usually seen in patients with diabetes, human immunodeficiency virus (HIV) infection, vascular disease, total parenteral nutrition, prolonged fasting, or being in intensive care unit (ICU) and in those with underlying history of trauma, burns and sepsis.
Surprisingly all our patients had recovered from Covid-19 and did not have the common and conventional predisposing factors mentioned above. It is postulated that Gallbladder epithelial cells are very similar to bile duct cells, as they richly express receptors (ACE2) and could be a target for SARS-CoV-2 or body’s dysregulated immunological response against the virus resulting in severe inflammation of gall bladder wall as well as the endothelial lining of the blood vessels resulting in subclinical coagulopathy and compromised blood supply of the cystic artery supplying the gall bladder thus resulting in mucosal edema ischemia and gangrene of gall bladder culminating in perforation in four of five cases in our series.
According to Dr. Shashi Dhawan, Senior Consultant Pathologist, Sir Ganga Ram Hospital, “These patients on histopathology showed features of severe inflammation along with evidence of ischemic injury of gall bladder wall with features of vascular injury of the blood vessels supplying the gall bladder in the form of endothelitis and deposition of fibrin thrombi suggestive of dysregulated immunological and vascular injury.
Prof. Anil Arora further added, few case reports of similar illness have been described in literature in its association with Covid-19 infection.
According to Dr. Praveen Sharma, Senior Consultant, Gastroenterology Department, Sir Ganga Ram Hospital, “In this smoldering pandemic a high index of suspicion of this entity in a patient with fever and right upper quadrant pain especially with history of recent recovery from Covid-19 infection a timely diagnosis and early intervention with broad spectrum antibiotics may prevent the development of onerous complication of gangrene and perforation of gall bladder.”
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