Abdo pain and fever
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Cholelithiasis is present. The gallbladder wall is thickened. Within the anterior wall, there is hyperechogenic curvilinear foci causing dirty shadowing, suggestive of intramural gas. This is seen to move with patient positioning. There is pericholecystic fluid. Sonographic Murphy's sign is positive.
The CBD is dilated (maximal diameter 12mm). No choledocholithiasis appreciated. Normal liver echotexture and echogenicity. No focal liver lesion. The portal and hepatic veins are patent. Ascites is present.
Acute emphysematous cholecystitis. Biliary dilatation without identifiable choledocholithiasis.
Emphysematous cholecystitis is uncommon and life threatening form of acute cholecystitis. It is also sometimes a complication of severe or untreated acute cholecystitis. It is a surgically emergency requiring urgent cholecystectomy or cholecystostomy due to a high risk of gallbladder gangrene and / or perforation.
In this case, the acute surgical team were made aware of the findings immediately after the scan. The patient was too unwell with a long list of comorbities for general anaesthesia and cholecystectomy and hence went onto to have a US guided cholecystostomy. Bile culture was positive for Klebsiella and Enterobacter species.
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