Case report: A case of cutaneous gallstones

Abstract

Gallbladder spillage during laparoscopic cholecystectomy procedures is common but rarely leads to patient morbidity due to complications such as abscesses or fistulas. We present the case of a 52-year-old woman post cholecystectomy, who presented to our dermatology clinic with abdominal pain and an epigastric subcutaneous nodule. The nodule was removed, leading to a complete resolution of her pain. On histopathology, it was found to be a cutaneous cholelithiasis.

Introduction

Cholelithiasis are stones that form from bile that hardens in the gallbladder. They are a common incidental finding in Caucasian adults and affect 9% of women and 6% of men in the United States. ¹ Besides a genetic susceptibility, ² patients with an elevated body mass index and multiparous women are especially at risk. ³ Gallstones are often asymptomatic but can become symptomatic by obstructing the biliary tree. When symptomatic, they initially present as biliary colic, with temporary obstruction of the cystic duct. More severe pathologies can occur when stones completely impact the cystic duct, or enter the bile ducts, obstructing other structures in their path. Several complications may arise, ranging from acute cholecystitis to cholangitis and pancreatitis. ⁴ The treatment is often surgical, with resection of the gallbladder (cholecystectomy), preventing stone formation and therefore subsequent obstructions. However, this problem, which appears to be surgical in nature, can sometimes involve dermatologists in the diagnosis. Rarely, gallstones can present on the skin following the formation of fistulas or following a laparoscopic surgery where stones are spilled and then left in the peritoneal cavity.

We present the case of a woman who developed a chronic indurated subcutaneous mass which was finally diagnosed as cholelithiasis.

Case report

A 52-year-old woman was initially referred to the dermatology clinic for an epigastric subcutaneous nodule and paroxysmal pain located around the nodule. The patient reported a 2-year history of epigastric pain and the appearance of a subcutaneous nodule. Her medical history included Charcot-Marie-Tooth disease, intellectual deficiency, diabetes, hypertension, gout, and venous insufficiency.

On physical examination, the patient had a subcutaneous nodule measuring approximately 2 × 3 cm, highly indurated, with a central ulceration, surrounded by erythema and painful on palpation. The presentation was initially suspicious for a neoplastic lesion, including a cutaneous metastasis, a dermatofibrosarcoma protuberans or an infiltrating squamous cell carcinoma.

An ellipse biopsy was performed to remove the entire nodule. A hard, grey mass was removed, suspicious for a foreign body, a large calcified cyst, such as an epidermoid cyst, a pilar or extrapilar cyst, or a pilomatrixoma.

We noticed the patient had already had an abdominal scan in 2021 for abdominal pain, which demonstrated a small subcutaneous nodule and signs of a previous cholecystectomy. A repeat computed tomography (CT) scan of the abdomen and pelvis was ordered to rule out the presence of a fistula and the patient was sent to general surgery to assess the findings of the scan. The second CT scan showed again a history of cholecystectomy, but also stigmata of chronic liver disease, adenopathy, and ascites of undetermined origin. A potential diagnosis of ovarian neoplasia was raised, and further investigations will be carried out by the surgical department. There was no evidence of fistula or infection.

Pathological examination revealed a near-spherical 1.5 cm calculus whose cut surface revealed a crystalline core and a dark amorphous shell, consistent with a combined-type cholelithiasis (see Figure 1).

Figure 1.

Microscopic view (hematoxylin-eosin stain, original magnification ×200). (a) Shell of calculus with alternating parallel zones of calcium carbonate (violet-blue) matrix and calcium bilirubinate (brown) matrix. (b) Granulation tissue surrounding calculus and including a few foreign body-type multinucleated histiocytes.

Following these investigations, it was concluded that a gallstone was most probably spilled and lost during her initial cholecystectomy and formed a subcutaneous indurated mass that was causing her epigastric pain. Her symptoms resolved following the elliptical excision of the mass.

Discussion

Symptomatic gallstones generally require cholecystectomy. Intraoperatively, gallstones may spill into the abdominal cavity, occurring at an incidence between 6% and 40%. ⁵ This complication only rarely leads to morbidity in about 0.08%–0.3% of cases. ⁶

More commonly patients may develop abdominal abscesses requiring drainage. Gaster et al. reported the story of a 72-year-old man who developed an abscess as well as a pleural effusion 6 months after undergoing cholecystectomy. ⁷ Rarely, patients with spilled gallstones, may also develop cutaneous complications such as sinus formation, granuloma formation, or colocutaneous fistulas. ⁶ For example, Kumar reported a patient, post cholecystectomy, presenting with a fistula extending from his skin to his peritoneum, ending with a walled off gallstone in the abdominal cavity. ⁸ Tham and Ng described a case of a 5 cm epigastric mass, which turned out to be an intraabdominal granuloma which was removed by laparotomy. ⁹

Our case showed that patients may not only develop peritoneal-cutaneous fistulas or granulomas but also cutaneous lithiasis. Despite their rare occurrence, cutaneous complications of cholelithiasis spillage should be kept in the differential diagnosis of abdominal nodular skin lesions, especially in patients who have undergone cholecystectomy. As well, if cutaneous lithiasis is suspected, a CT scan is warranted to rule out the presence of a concomitant fistula. Depending on the findings, a consultation in general surgery can be considered. We consider that the CT findings in this case were incidental, and not related to the presence of the cutaneous lithiasis. We are reassured that no fistula or infection was detected, and the other findings will be assessed by the surgery team.

Some authors have highlighted that the use of laparoscopy in recent years could lead to an increase in the incidence of spilled and lost gallstones since, during an open cholecystectomy, spilled gallstones are more easily found and removed.^5,10,11 Our patient’s case further supports the need to avoid gallstone spillage upon resection and prompts us to add the diagnosis of cutaneous lithiasis to our differential diagnosis of subcutaneous nodules, particularly in the post-operative context.