Acute cholecystitis with contained perforation

Case contributed by Dr Bruno Di Muzio

Presentation

Abdominal pain and vomiting. Mildly deranged LFT's,

Patient Data

Age: 90 years
Gender: Female

CT Abdomen and pelvis

CT

Findings are suggestive of acute cholecystitis with an impacted stone at the gallbladder neck and findings suggesting a contained perforation at the gallbladder fundus. The gallbladder is elongated with an 'S' shaped configuration. There is intra and extrahepatic duct dilatation with the common bile duct measuring up to 13 mm. The pancreatic duct is also dilated throughout. US correlation is suggested.

US Abdomen

Ultrasound

Distended gallbladder with impacted stone at the neck. Fluid-fluid levels from sludge. Localized perforation at the anterior aspect of the gallbladder fundus with contained collection (transverse images). Sonographic Murphy's positive. The common bile duct is not dilated, measures 6 mm.

Courtesy of Dr. Henry Knipe

US-guided Cholecystostomy

Ultrasound

US-guided cholecystostomy was performed as the patient did not have clinical conditions for surgery at that moment. 

Tubogram

Fluoroscopy
Tubogram study: Right-sided cholecystostomy tube noted in situ. Contrast (Omnipaque 240) was administered through the tube while images were obtained. Findings: Contrast flowed smoothly filling the gallbladder the into the convoluted cystic duct .The larger known gallbladder calculus at the gall bladder neck is again noted. There are no convincing filling defects within the cystic duct nor within the common bile duct. The common bile duct decompressed into the small bowel as expected. There is no evidence of reflux into the proximal biliary tree. No extraluminal contrast extravasation.

Case Discussion

Gallbladder perforation is a relatively rare complication related to acute cholecystitis. It can carry a relatively high mortality rate. This case illustrates an impacted stone at the gallbladder infundibulum, signs of acute cholecystitis and a contained perforation at the gallbladder fundus.

Percutaneous cholecystostomy was done until stabilization of a patient to enable a more measured surgical approach. A cholecystectomy was performed some days later the presentation. 

 

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