Acute cholecystitis

Case contributed by Dr Bruno Di Muzio

Presentation

Voluntary guarding of the abdomen.

Patient Data

Age: 75 years
Gender: Male
Ultrasound

Abdomen

The gallbladder is distended and edematous with surrounding hyperemia (wall thickness 0.4 cm). Mobile calculi and sludge are present within its lumen.
Small volume free fluid in the right upper quadrant.

The common bile duct is dilated to 0.8 cm with low-level internal echoes seen throughout its lumen to the level of the ampulla.  No CBD stone identified anywhere along its course.  There is intra-hepatic duct dilatation as seen on the recent CT. The pancreatic duct is not dilated.

The main portal vein is patent and demonstrates normal directional blood flow.

Conclusion:
1. Features in keeping with acute calculus cholecystitis.
2. Dilatation of the intra and extrahepatic ducts as seen on CT. The CBD was well visualized with sludge seen throughout its lumen. No evidence of a CBD stone.

MRI

MRCP

There is a 4.5 mm rounded filling defect at the distal end of the common bile duct, at the papilla level, suggestive of intra ductal stone. The CBD is dilated (8.0 mm) and has some inspissated bile within. Mild intra-hepatic dilatation.  No other intraductal stones.

The gallbladder is distended and has thick walls showing diffusion restriction consistent with acute cholecystitis. Multiple gallstones. Small amount of free fluid in the superior abdomen.

The pancreas has normal morphology and signal intensity, there is no abnormal dilatation of the main pancreatic duct.  The liver has a normal signal intensity.  The spleen, adrenal glands, and kidneys are normal.  There is no lymphadenopathy.

Conclusion:

1. Distal 4.5 mm CBD stone and mild biliary tree dilatation.

2. Features consistent with calculous cholecystitis.

Macroscopy: Labelled "Gall bladder". Disrupted gallbladder measuring 97 x 37 mm. Wall thickness is up to 10 mm. Mucosa is grey/brown with roughened texture. 3 yellow pigmented gallstones, the largest 17 mm. No lesions are identified. Cystic duct node is not identified.

Microscopy: The sections of the gallbladder wall show broad areas of ulceration, the residual epithelium shows reactive changes. There is an associated dense transmural active chronic inflammatory cell infiltrate extending into the adventitia where there are a prominent reactive fibroblastic response and abscess formation. The included mesothelium shows areas of fibrinous serositis and reactive changes. The cystic duct node shows reactive features. There is no evidence of malignancy. 

Conclusion: Gallbladder: Acute cholecystitis and cholelithiasis. 

Case Discussion

As a common practice in emergency radiology, this case illustrates typical sonographic features of cholecystitis. MRCP has confirmed ductal stones and the patient was primarily managed with ERCP and sphincterectomy. He was booked for a laparoscopy cholecystectomy one week after. 

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Case information

rID: 72392
Published: 7th May 2020
Last edited: 7th May 2020
Inclusion in quiz mode: Included

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