Point-of-care ultrasonography in the diagnosis of hemorrhagic cholecystitis

An 81-year-old man presented to the emergency department with a 1-day history of right upper quadrant abdominal pain, without fever or vomiting. Sixteen days before presentation, he had undergone coronary artery bypass surgery for an ST elevation myocardial infarction, and was prescribed clopidogrel and acetylsalicylic acid postoperatively. Physical examination showed right upper abdominal tenderness without guarding and a negative Murphy sign. Laboratory investigations showed elevated levels of white blood cells, bilirubin, aspartate transaminase, alanine transaminase and alkaline phosphate. Based on these findings, the patient underwent endoscopic retrograde cholangiopancreatography; sphincterotomy and sphincteroplasty yielded a large cast of bile-stained clot. As no predisposing structural or vascular abnormalities were detected, we diagnosed hemorrhagic cholecystitis secondary to the recent initiation of antiplatelet therapy. After the procedure, the patient's lab abnormalities and pain resolved, and he was discharged with consideration for an outpatient cholecystectomy once antiplatelet agents were discontinued.