Acute cholecystitis with tensile fundus sign

Case contributed by Dr Michael P Hartung

Presentation

Right abdominal pain, evaluate for renal stones.

Patient Data

Age: 65
Gender: Female

Cholelithiasis, dilated gallbladder, tensile fundus indenting the body wall, and pericholecystic inflammation/stranding. Reactive inflammation of the hepatic flexure. 

CT

Annotated images

Arrows indicate the tensile fundus sign, with the gallbladder fundus indenting the body wall. 

Case Discussion

The patient was treated with subtotal cholecystectomy due to extensive adhesions and tissue inflammation. 

This case illustrates a few important points:

  • it is fairly common to have a pathology other than renal stones accounting for abdominal pain on a renal stone study. In particular, I come across diverticulitis, appendicitis, colitis, epiploic appendicitis, omental infarct, acute cholecystitis, and pancreatitis. I recommend reading those studies with the same search pattern as a contrast-enhanced study. 
  • CT is excellent for the diagnosis of acute cholecystitis. It is almost reflexive to order an ultrasound examination when talking about acute cholecystitis, but completely unnecessary in the vast majority of cases when it is seen on CT. Ultrasound will NOT show pericholecystiic inflammation or reactive inflammation of the hepatic flexure, which is easily detected on CT, and therefore may actually lower diagnostic confidence. 
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Case information

rID: 71394
Published: 2nd Oct 2019
Last edited: 2nd Oct 2019
Inclusion in quiz mode: Included

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