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Abdomen » Hepatobiliary
Complicated acute calculous cholecystitis - with perforation
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Presentation An elderly woman, with a history of lung cancer presents with vague pain in the abdomen. However, she reports a single episode of severe excruciating pain in the right upper quadrant [RUQ] one week earlier.
 
 
 
Caption: Transverse scan of the RUQ.
Description: The gallbladder is distended and filled with sludge. An irregular serpingineous echogenic structure is seen alongside one of the walls. Also noted are multiple tiny echogenic foci alongside the opposite wall, suggestive of calculi.
 
 
 
Caption: Sagittal scan of the gallbladder.
Description: The distended gallbladder is seen, showing the echogenic septa alongside both walls extending into the lumen. These septa either represent the sloughed mucosal lining-a sequel to the patient’s episode of acute cholecystitis one week prior or adherent sludge.
 
 
 
Caption: Magnified view of the gallbladder lumen.
Description: The distended gallbladder, luminal sludge and the irregular echogenic lining on the near wall are depicted much more clearly in this image.
 
 
 
Caption: Color Doppler image of the gallbladder.
Description: No increased vascularity is noted within the gallbladder wall.
 
Differential Diagnosis Sloughed mucosal lining as a sequel to prior episode of acute cholecystitis versus adherent sludge
 
Final Diagnosis Acute cholecystitis with perforation
 
Discussion The case shown here demonstrates one of the signs associated with perforation of the gallbladder, a life threatening complication. The other complications of an acutely inflamed gallbladder include peritonitis, abscess formation, ascending cholangitis, empyema formation and conversion to emphysematous or gangrenous cholecystitis.

Pathogenesis of gallbladder wall perforation: Madrazo, et al has implicated –

  • Calculous obstruction of the cystic duct,
  • Causing luminal distention, leading to vascular compromise of the gallbladder wall and
  • Subsequent ischemia and necrosis, resulting in a perforation of the gallbladder.

Ultrasound is the initial, and many times the only, modality used to image the gallbladder. No sonographic signs that would suggest imminent perforation have been described and therefore all cases of acute cholecystitis that are being managed conservatively must be followed up till complete resolution. Perforation, when it occurs shows the following ultrasound features-

  • The usual signs of acute cholecystitis,
  • A discontinuity or defect in the gallbladder wall at the site of perforation.
  • Serpiginous intraluminal membranes due to sloughed mucosal lining.
  • One or more hypoechoic or complex heterogeneous masses adjacent to the gallbladder, representing peri-cholecystic fluid collections or abscesses.

A recent report by Konno, et al emphasizes the significance of color Doppler in detecting the defect in the gallbladder wall as a flow signal passing through the perforated site.

The case illustrated here shows irregular, linear echogenic material along the gallbladder wall, which raises a suspicion for sloughed mucosa. However, adherent or linear sludge can also create this appearance and pathologic proof is lacking in this case. No fluid collections were seen in the area around the gallbladder, so the ultrasound did not specifically suggest perforation but in the presence of a sloughed lining it should be considered a possibility.  A CT scan performed the following day, after the patient experienced another episode of severe right upper quadrant pain, showed the defects in the gallbladder wall due to perforation. Ultrasound and CT findings are almost comparable in the detection of perforation, although certain studies find CT to be superior.

 
Case References 1. Wales LR. Desquamated gallbladder mucosa: unusual sign of cholecystitis. AJR. 1982 Oct; 139: 810.
2. Forsberg L, Andersson R, et al. Ultrasonography and gallbladder perforation in acute cholecystitis. Acta Radiol. 1988 Mar-Apr; 29(2):203-5.
3. Madrazo BL, Francis I, et al. Sonographic findings in perforation of the gallbladder. AJR. 1982 Sep; 139(3):491-6.
4. Sood BP, Kalra N, et al. Role of sonography in the diagnosis of gallbladder perforation. J Clin Ultrasound. 2002 Jun; 30(5):270-4.
5. Konno K, Ishida H, et al. Gallbladder perforation: color Doppler findings. Abdom Imaging. 2002 Jan-Feb; 27(1):47-50.
6. Lameris JS, Jeekel J, et al. Percutaneous transhepatic cholecystostomy. ROFO Fortschr Geb Rontgenstr Nuklearmed. 1985 Jan; 142(1):80-2.
7. Jurkovich GJ, Dyess DL, et al. Cholecystostomy. Expected outcome in primary and secondary biliary disorders. Am Surg. 1988 Jan; 54(1):40-4.
 
Follow Up One day following the ultrasound, the patient started to complain of severe pain in the RUQ and a contrast enhanced CT scan was performed, which showed at least two areas of break in the gallbladder wall and a 4 cm pericholecystic collection compatible with perforated cholecystitis. Surgery was deferred due to the associated co-morbid conditions and ultrasound guided cholecystostomy was performed. Three hundered ml of purulent bilious fluid was drained. The gallbladder was opacified with a very small amount of contrast, which however, did not show the sites of rupture. The patient`s symptoms gradually resolved.
 
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