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Abdomen » Hepatobiliary
Complicated acute calculous cholecystitis -empyema of the gallbladder
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Author(s) :
Deepak Chawla, MD
 
Presentation A very obese woman presents with acute pain in the right hypochondrium and fever. An ultrasound was performed.
 
 
 
Caption: Scan of the right hypochondrium
Description: The gallbladder shows a large calculus with posterior shadowing. The walls of the gallbladder appear thickened and indistinct, and exhibit scattered punctate high-amplitude echoes, suggesting emphysematous cholecystitis.
 
 
 
Caption: Sagittal scan of the right upper quadrant
Description: The gallbladder with calculus is again demonstrated. No portion of the gallbladder lumen can be reliably identified. There was tenderness over the area with transducer pressure while scanning.
 
 
 
Caption: Transverse image of right upper quadrant
Description: The thickened walls of the gallbladder are better seen here and a small portion of the hypoechoic lumen of the gallbladder is seen just above the calculus.
 
Differential Diagnosis Pyogenic/empyema of the gallbladder or emphysematous gallbladder
 
Final Diagnosis Pyogenic gallbladder with cholelithiasis
 
Discussion

The ultrasound appearance of acute calculous cholecystitis has been discussed in a previously published case [click here to view]

This case has been illustrated here to demonstrate one of the complications of acute cholecystitis - empyema of the gallbladder. Bacterial infection of the bile in the obstructed gallbladder typically results in empyema, a distended gallbladder filled with pus and debris.  If untreated, pyogenic cholecystitis may lead to generalized sepsis and/or gangrene/perforation of the gallbladder.

In a typical case of cholecystitis complicated by empyema, along with the usual ultrasound findings of cholecystitis, a distended gallbladder filled with fluid that shows multiple echoes and debris will be seen.

Sometimes in cases of calculous cholecystitis, calculi fill the lumen to such a great extent [as in this case] that it is not possible to assess the echogenicity of the bile, the hallmark of empyema. In this case, ultrasound alone is of limited use to diagnose pus within the gallbladder. Combined ultrasound, clinical and laboratory criteria may help arrive at the correct final diagnosis.

 
Follow Up This patient was operated and the diagnosis was a pyogenic gallbladder with cholelithiasis.
 
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