At our institution, a 13-month-old, healthy, full-term girl presented with a 36-h history of non-bilious, non-bloody emesis, diffuse abdominal pain, and lethargy. There was no recent travel or known exposure to dirty water, incorrectly prepared food, or animal feces. On arrival, she was tachycardic with low-grade temperatures to 100.5°F. Labs were notable for a normal hematocrit/hemoglobin and a white blood cell count of 14,970 (per μL), without a left shift. AST/ALT were 30/23 (U/L) respectively, total bilirubin was 0.6 (mg/dL), and alkaline phosphatase was 1047 (U/L). An abdominal ultrasound was obtained that showed only a few scattered lymph nodes and was non-diagnostic. A computed tomography scan was notable for gallbladder thickening and distention, non-specific free fluid, and small bowel thickening (Fig. 1).
Upon evaluation by the pediatric surgery, there was evidence of peritonitis on examination with diffuse abdominal tenderness, guarding, and rebound. Intravenous piperacillin-tazobactam was started, and she was taken for emergent diagnostic laparoscopy after resuscitation.
On laparoscopy, there was a large amount of white, non-malodorous pus in the abdomen and a normal appearing appendix. The examination of the abdomen with the laparoscope revealed a significantly distended gallbladder (Fig. 2) with omentum and duodenum adherent to the gallbladder. The aspiration of the gallbladder revealed frank pus. The laparoscopy was converted to an open procedure as exposure to the biliary tract was limited by inflammatory adhesions. There was no frank perforation in the gallbladder. While there was no perforation of the gallbladder, we hypothesize that the generalized peritonitis was secondary to transmural spread of the bacteria. A cholecystostomy tube and a Jackson-Pratt drain were placed.
The culture of the pus obtained from the lumen of the gallbladder was positive for Salmonella typhi on postoperative day 1, and intravenous antibiotics were changed to ceftriaxone 50 mg/kg two times per day for 14 days. The patient progressed well and by POD # 5 was tolerating a regular diet. Repeat complete metabolic panel prior to discharge was normal and notable for decreased alkaline phosphatase (639 units/L), normal AST/ALT (27/13 units/L), and total bilirubin (< 0.3 mg/dL). No postoperative inflammatory markers were obtained after antibiotic treatment. Ceftriaxone was continued until discharge per infectious disease recommendations, and the patient was transitioned to oral amoxicillin/clavulanic acid until follow-up in clinic. Prior to her discharge, her drain was clamped. She was seen in clinic 2 weeks after in good spirits, with scant drain output when unclamped in clinic, tolerating a regular diet without abdominal pain or additional episodes of emesis. Eight weeks after placement of the cholecystostomy tube, a cholangiogram (Fig. 3) revealed normal biliary anatomy, and the cholecystostomy tube was removed. The patient has remained asymptomatic and is doing well over 9 months later.