Cholecystitis with focal perforation and hepatic abscess

Case contributed by Dr Craig Hacking

Presentation

Right sided abdominal pain and fevers. Hx Crohn's disease. On methotrexate.

Patient Data

Age: 63
Gender: Male

No intravenous contrast is given due to poor renal function.

1 cm calculus is noted at the neck of the gallbladder. Small amount of stranding is seen around the gallbladder. No pericholecystic fluid.

No intra-abdominal collection. No intraperitoneal free gas or fluid.

Rounded 1.5 cm hypodense lesion is seen within hepatic segment IVb, immediately adjacent to the gallbladder fossa. This may represent an area of fatty liver.

5 mm left renal hyperdense lesion. Small left nephrolithiasis. Large and small bowel are within normal limits.

Bilateral lower lobe atelectasis. No suspicious osseous lesion.

Conclusion

  1. Cholecystitis with a stone impacted at the neck.
  2. No intra-abdominal collection.
  3. The hypodense hepatic lesion should be further assessed on ultrasound.

Increased liver echogenicity is in keeping with fatty infiltration with focal fat-sparing adjacent to the gallbladder fossa. Also adjacent to the gallbladder fossa is a focal region that is predominantly anechoic with multiple septations and no vascularity (segment 4a).

A calcified shadowing calculus is noted within the gallbladder neck/cystic duct and appears a little larger than on the CT, measuring up to 2 cm on ultrasound. Gallbladder wall appears thickened and slightly irregular although when measuring it, it is on the upper limits of normal. The gallbladder is mildly distended. There is no extrahepatic or intrahepatic bile duct dilatation. The patient certainly was not probed tender at Murphy's point but displayed generalised right-sided tenderness. I note the thickened and slightly narrowed appearance of the terminal ilium on the CT from earlier today, keeping the Crohn's disease. The appendix appears normal on the CT.

The spleen is normal. The pancreas is not well visualised due to overlying bowel gas.

Both kidneys were normal, with the hyperdense left renal lesion seen on CT not identified on ultrasound.

Conclusion

Ultrasound features are equivocal for acute calculus cholecystitis but this is still the most likely diagnosis given the patient's immunosuppression due to Crohn's disease. The hepatic lesion adjacent to the gallbladder in this context represents an abscess until proven otherwise.

Case Discussion

The patient underwent cholecystectomy which revealed a perforated inflamed gallbladder with a small adjacent hepatic abscess.

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Case information

rID: 37189
Case created: 28th May 2015
Last edited: 3rd Oct 2015
Inclusion in quiz mode: Included

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