Presentation
Prior history of non Hodgkin lymphoma, and multiple small bowel resections. On TPN. Now febrile with upper abdominal pain.
Patient Data
Gallbladder is distended and filled with heterogeneous solid material which is roughly isoechoic to the liver parenchyma. There is no internal flow on Doppler examination, and the gallbladder wall is unremarkable in thickness, and is not hypervascular. Common bile duct is not dilated, measuring 5 mm in diameter at the porta hepatis.
Conclusion
The most likely explanation for the appearance of the gallbladder is sludge, probably related to TPN administration.
The gallbladder is distended, and although the wall appears to enhance, near the fundus a focal region of 'sloughed' mucosa is seen.
Markedly distended gallbladder with non enhancing sections of wall is demonstrated. Over the last three CT scans it has progressively become more distended, and developed areas of non enhancing wall, with associated stranding in the fat surrounding the fundus. In addition there is an increase in the amount of fluid adjacent measuring 7 x 4 x 10cm which as yet does not have enhancing margins.
No free intraperitoneal gas. The liver, spleen, pancreas, kidneys and adrenals are unchanged since previous imaging.
Right pleural effusion is unchanged, right basal atelectasis has progressed. On the left a small pleural effusion has developed and left basal atelectasis is now demonstrated.
Informed consent, prep and drape, 2% lignocaine skin anesthesia. Under ultrasound guidance an 8 French Navarre pigtail catheter was inserted into the gall bladder via the fundus. Black bile was aspirated, and sent for M/C/S. A drainage bag was attached. No immediate complications.
Cholecystostomy tube is in situ. The gallbladder is distended, thick walled with moderate surrounding fluid consistent with known cholecystitis. There is heterogeneous mixed signal material in the gallbladder lumen, presumably representing sludge/inflammatory exudate. Sloughed membranes noted. There is no biliary dilation with the common duct measuring 7 mm at the porta hepatis. No convincing filling defect is seen in the duct to suggest choledocholithiasis.
In the liver there are multiple patchy T2 hyperintense and T1 hypointense foci, largest in the segment VII measuring 2.7 cm. These areas correspond to hypoattenuating areas on recent CTs from 15/6/12 and 11/6/12 which on CT appear to be improving on serial scans. These are not clearly abscesses. Mild hepatic steatosis.
Small amount of free fluid is noted around the liver/spleen, left paracolic gutter, within the lesser sac and the Morrison's pouch. There are renal cysts.
Conclusion:
Gangrenous Cholecystitis. No choledocholithiasis, biliary dilation or Mirrizzi syndrome.
MACROSCOPIC DESCRIPTION:
A gallbladder 100x65x38mm. The mucosa is flat and wall thickness up to 12mm. The serosa is patchy. The lumen contains soft yellow greenish material.
MICROSCOPIC DESCRIPTION:
Sections show gallbladder which has acute inflammation extending through the gallbladder wall with areas of necrosis of the gallbladder wall. The mucosa is completely denuded. No evidence of dysplasia or malignancy is seen.
DIAGNOSIS:
Gallbladder: Acute gangrenous cholecystitis, cholelithiasis.
Case Discussion
Typical appearances of gangrenous cholecystitis.