Presentation
Chronic right upper quadrant pain, nausea, weight loss and loss of appetite.
Patient Data
Post contrast CT in portal venous phase imaging showing a gall bladder which is not normal. GB is very inflamed with ill-defined fluid collections adjacent to gall Bladder, anterior to liver, inflammatory changes in the ascending colon, hepatic flexure and duodenum. Air in the GB fossa and in duodenum, should increase the radiologist's suspicion for a complication of chronic cholecystitis like a cholecystoduodenal fistula.
Hepato biliary imaging after ERCP
Hepatobiliary scan with no uptake into the gall bladder suggesting cystic duct obstruction. The tracer is flowing normally into the duodenum without a biliary leak.
Percutaneous cholangiogram after all studies.
PTC showing the connection between
1. the gall bladder and duodenum,
2. There is leak of contrast from gall bladder fundus.
3. There is a stent in the pancreatic duct.
3 days after 1st CT & immediately after ERCP
CT scan with contrast showing an inflamed GB and air in the GB fossa with severe pericholecystic inflammatory changes. However, there is an improvement in the fluid collection from the CT 3 days prior. Differential diagnosis include gangrenous cholecystitis with cholecystoenteric fistula. This was confirmed on PTC performed subsequently.
Case Discussion
He had an initial single phase CT which was abnormal and was referred for ERCP which was done 3 days after first CT. They had difficulty to cannulate the CBD but could place a stent in pancreatic duct.
A repeat CT was done after ERCP. Small amount of pus was seen in the duodenum suspecting a cholecysto duodenal fistula.
This was confirmed by PTC.
Patient underwent a satisfactory PTC placement of a cholecystostomy tube and 8 weeks later under cholecystectomy which showed chronic cholecystitis and perforation without any cancer.
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