Cholecystitis: perforated gallbladder

Case contributed by Dr Yair Glick

Presentation

Right upper quadrant pain, vomiting, fever.

Patient Data

Age: 60-65 years
Gender: Male
Ultrasound

The gallbladder contains sludge and small stones and its walls are thickened (up to 5 mm) and striated but it is not distended. Perhaps gallbladder wall thickening is secondary to heart failure.
Perceived loss of gallbladder wall integrity in the fundus.
Minimal amount of free perihepatic and perisplenic fluid.

Cortical cysts in both kidneys, including a huge one in the left kidney.

The prostate is markedly enlarged.

Nasogastric tube in the stomach.

Status post-sternotomy and CABG to LAD. The cardiac compartments are enlarged. Old anteroseptal infarction with apical aneurysm.

Small amount of bilateral pleural effusion with subsegmental bibasal pulmonary atelectasis.

Thickened gallbladder walls with mucosal enhancement. Mild pericholecystic fat stranding.

Moderate amount of free intraperitoneal fluid, mostly perihepatic, perisplenic, and pelvic.

Simple renal cortical cysts, the largest is in the left kidney and measures 9 cm across.

Sigmoid diverticulosis.

Case Discussion

The patient presented with right upper quadrant pain that appeared on the same day, a single episode of vomiting, and a rise in temperature. Lab tests were remarkable for leukocytosis with neutrophilia.
History of diabetes mellitus type 2, hypertension, hyperlipidaemia, and moderate-to-severe left ventricular failure.

The ultrasound and CT examinations were performed only several hours apart.

Following CT, the patient underwent exploratory laparoscopy. Biliary peritonitis in all four quadrants was observed, at which point conversion to laparotomy was performed. A perforated gallbladder was excised.

Upon revision of the radiological exams, while there is perceived interruption in the integrity of the gallbladder fundus wall, one cannot assuredly diagnose gallbladder perforation. In the appropriate clinical context, abnormal radiological findings should raise the level of suspicion for complicated cholecystitis. 1

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Case information

rID: 57038
Case created: 4th Dec 2017
Last edited: 5th Dec 2017
Inclusion in quiz mode: Included

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