Acute cholecystitis with gallbladder neck calculus

Case contributed by Derek Smith

Presentation

3 days of right upper quadrant and epigastric pain with vomiting. Tender to palpation in right upper quadrant. Raised inflammatory markers but normal liver function tests.

Patient Data

Age: 45 years
Gender: Female

Thickwalled gallbladder (measuring 6 mm) with large calculus obstructing the neck. Sludge in the gallbladder but no other calculi, nor in the ducts. Trace pericholecystic fluid.

Dilated common bile duct (about 8 mm) with intrahepatic biliary dilatation. Patent portal vein.

Thickened gallbladder, with a trace of pericholecystic fluid. 

Large impacted calculus at the gallbladder neck with multiple dependent calculus within the gallbladder.

Mild intra and extrahepatic biliary dilatation with dilated CBD (8 mm). No ductal calculi or obstructing lesion identified.

Low medial insertion of the cystic duct. Normal caliber pancreatic duct.

Case Discussion

This patient presented with right upper quadrant/epigastric pain and tenderness, vomiting and raised inflammatory markers. Although the liver function tests were within normal ranges, ultrasound demonstrated a number of features in keeping with acute cholecystitis (thickened gallbladder wall, pericholecystic fluid) as well as potential cause (large calculus in the gallbladder neck) and some potential complications (biliary dilatation). 

The patient proceeded to MRCP to further characterize this and excluded any ductal stones. MRCP also cleared pancreatic duct involvement, and highlighted the low medial insertion of the cystic duct which is a common normal variant of biliary anatomy but important when considering surgical resection.

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