Acute calcular cholecystitis

Case contributed by Dr Safwat Mohammad Almoghazy

Presentation

Acute right upper quadrant abdominal pain. Elevated liver function tests and suggesting biliary obstruction.

Patient Data

Age: 55 years
Gender: Female

On the day of presentation

Ultrasound

The gall bladder is distended with a large stone lodged in the Hartman pouch measuring about 2cm with echogenic biliary mud within and has diffuse wall thickening, but no pericholecystic fluid noted collections.

MRCP on day 3

MRI

The gallbladder is distended and an impacted stone in its neck appearing as a rounded filling defect measuring about 2 cm is noted, with diffuse wall thickening and minimal pericholecystic inflammatory fatty stranding impressive of acute calcular cholecystitis.

Normal caliber and outline of intrahepatic bile ducts, right/left common hepatic, cystic duct and common bile ducts
No evidence of free fluid or lymphadenopathy is detected. 
The bilateral minimal pleural reaction is noted. 

Conclusion:
Features on MRI are compatible with acute cholecystitis with impacted stone at the neck of the gallbladder.

Case Discussion

This case is an excellent example of a large population who are visiting the hospital with one of the gallstone-related diseases.  

Acute cholecystitis is one of the most common reasons for hospital admission with acute abdominal pain. Approximately 90–95% of acute cholecystitis is related to gallstones, with 5–10% of cases due to acalculous disease.

Calculous cholecystitis refers to infection and inflammation of the gallbladder wall caused by irritation from gallstones, and this can be an acute or chronic process.

The typical imaging features of acute cholecystitis are as follows: gallbladder wall thickening, pericholecystic fluid and a distended gallbladder.

As such, ultrasound is the imaging modality of choice for the initial assessment of suspected gallbladder pathology.

Magnetic resonance cholangiopancreatography (MRCP) is typically performed using heavily T2-weighted sequences which are particularly helpful in delineating ductal anatomy. Gallstones typically appear as low signal or signal void on T2-weighted imaging surrounded by T2 hyperintense bile. MRCP has largely replaced endoscopic retrograde cholangiopancreatography (ERCP) as the gold standard for diagnosing choledocholithiasis due to its high sensitivity of 90–94% and specificity of 95–99% without the use of ionizing radiation or ERCP-related complications such as pancreatitis which can result in significant morbidity and even mortality.

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