When the Gallbladder Hurts the Thigh: Silent Gallbladder Empyema With Perforation Presenting as Severe Rhabdomyolysis

Gallbladder empyema and perforation are severe complications of acute cholecystitis that typically present with abdominal pain, fever, and systemic inflammation.However, clinically silent or atypical presentations may occur, particularly in older patients with diabetes and multiple comorbidities, potentially resulting in delayed diagnosis.This is a case of gallbladder empyema complicated by perforation and biliary leakage that presented predominantly with severe thigh pain and rhabdomyolysis, in the absence of abdominal symptoms.A 71-year-old man with type 2 diabetes mellitus, peripheral vascular disease, chronic kidney disease, ischaemic heart disease, and heart failure with reduced ejection fraction presented with fever, generalised weakness, severe right thigh pain, and inability to mobilise.He consistently denied abdominal pain.Initial investigations revealed marked systemic inflammation, with a white cell count of 28-32 × 10⁹/L and a Creactive protein (CRP) of 580-616 mg/L.He had acute kidney injury (peak creatinine 406 μmol/L), hyperphosphataemia, and a markedly raised creatine kinase (CK) of 16,697 U/L, consistent with rhabdomyolysis (McMahon score > 6).MRI of the pelvis and femurs demonstrated bilateral, rightpredominant muscle oedema without evidence of an intramuscular collection.Non-contrast CT of the abdomen revealed a markedly distended and inflamed gallbladder with adjacent subcapsular and perihepatic collections suggestive of gallbladder perforation with biliary leakage.Ultrasound-guided drainage of the perihepatic collection yielded bilious fluid.The gallbladder empyema was subsequently managed with endoscopic ultrasound-guided cholecystogastrostomy using a Hot AXIOS lumen-apposing metal stent (Boston Scientific Corp., Natick, MA, USA), allowing drainage of purulent bile.Subsequent endoscopic washout was performed, with placement of two pigtail stents through the AXIOS stent.Following antibiotic treatment and biliary source control, inflammatory markers, CK, and renal function improved, with resolution of the thigh pain and improvement in mobility, allowing discharge home.Gallbladder empyema complicated by perforation can occur without abdominal pain and may present predominantly with extra-abdominal features.In older patients with diabetes and multiple comorbidities who present with unexplained sepsis, an occult intra-abdominal source should be considered even when abdominal symptoms and signs are absent.Although the direct mechanism linking biliary infection to rhabdomyolysis remains uncertain, the parallel resolution of sepsis, CK, renal function, and thigh pain after antibiotic treatment and biliary drainage supports the infection as the unifying driver.This case also demonstrates that endoscopic ultrasound-guided gallbladder drainage with a lumen-apposing metal stent offers an effective and minimally invasive alternative to surgery for source control in patients with high operative risk.