Bilateral adrenal hemorrhage after colectomy for perforated diverticulitis: A case report.

INTRODUCTION: Bilateral adrenal hemorrhage can lead to acute adrenal insufficiency. This is a rare complication in the post-operative setting, and we present a case in which it developed after a colectomy for perforated diverticulitis. PRESENTATION OF CASE: The patient is a 65-year-old female who presented with abdominal pain, nausea, emesis, and hematochezia, and CT scan showing sigmoid diverticulitis with peri-sigmoid abscess. After a failure of non-operative treatment, she underwent Hartmann's resection, and her post-operative course was complicated by refractory tachycardia, hypotension, hyponatremia, and nausea/vomiting. Bleeding, hypovolemia, and sepsis were ruled out. A CT scan showed enlarged poorly defined adrenals bilaterally, suggestive of bilateral adrenal hemorrhage. Serum cortisol level was low and diagnostic of acute adrenal insufficiency. With intravenous steroid therapy (hydrocortisone), her vital signs, laboratory abnormalities, and diet intolerance all resolved. She was discharged on oral prednisone and continued long term. DISCUSSION: Bilateral adrenal hemorrhage is rare post-operatively and can lead to adrenal insufficiency. 15% of patients who die in shock have bilateral adrenal hemorrhage on autopsy, indicating the necessity of timely diagnosis and treatment of this condition. Corticosteroid therapy is the mainstay of treatment. CONCLUSION: This case study illustrates that post-operative delay of progression or worsening of condition, with no alternative explanation, can be due to acute adrenal insufficiency resulting from bilateral adrenal hemorrhage, and timely diagnosis and treatment of this condition is paramount for a favorable outcome.

Cholecystocolonic fistula: A rare case report of Mirizzi syndrome.

INTRODUCTION: Mirizzi syndrome is a rare complication of gallstone disease that more rarely is associated with the formation of cholecystoenteric fistula. PRESENTATION OF CASE: The patient presented with a five-day history of abdominal pain in the right upper quadrant (RUQ), nausea, and emesis. Further ultrasound (US) imaging demonstrated a large gallstone with associated thickened gallbladder with pericholecystic fluid. Computed tomography (CT) imaging, preoperative Hepatobiliary Scintigraphy and Endoscopic Retrograde Cholangiopancreatography (ERCP) displayed findings consistent with a Csendes type IV Mirizzi syndrome associated with cholecystocolonic fistula. Description of surgical approach, management and outcome is presented. DISCUSSION: Surgical management of Mirizzi syndrome varies by classification of its severity. Open operation is preferred in cases with severe inflammation and concern for malignancy. The patient underwent a cholecystocolonic fistula takedown. A cholecystectomy was attempted though aborted due to concerns of malignancy. Biopsies returned negative for malignancy and the patient demonstrated findings on ERCP consistent with Mirizzi syndrome. Stenting of the common bile duct (CBD) was performed with ERCP and later the patient underwent an open biliary exploration with subsequent choledochotomy, biliary stone removal, and primary closure with interrupted sutures using remnant gallbladder wall flaps. CONCLUSION: To our knowledge, Mirizzi syndrome with concurrent cholecystocolonic fistula is exceedingly rare with a paucity of reports within the literature. Our report discusses principles of management of Mirizzi syndrome as well as best practices of surgical management for Mirizzi syndrome with concurrent cholecystocolonic fistula.