Hemorrhagic cholecystitis

Case contributed by Dr Umberto Pisano

Presentation

Presented with acute upper abdominal peritonism. She had been discharged from internal medicine ward a few days earlier, following an intentional drug overdose (presumably a combination of tricyclic antidepressants, methotrexate, warfarin, acetaminophen). Background of atrial fibrillation, rheumatoid arthritis, depression, hypercholesterolemia. Known to have gallstones according to US a few years prior.

Patient Data

Age: 80 years
Gender: Female
CT

CT abdomen and pelvis with contrast

Large pericholecystic collection of intermediate density (30-40) associated with crescentic blush of contrast in the gallbladder bed. On thick MIP reformats (coronal image), the contrast extravasation can be traced back to the cystic artery.

The gallbladder itself is not outlined and does not show any enhancement.

Moderate amount of fluid in the abdomen and pelvis.

Incidental anterior interposition of the colon under right hemidiaphragm.

CT

CT angiography

On this axial arterial volume of the CT angiography performed shortly after the first, the bleeding has subsided 

No cystic artery pseudoaneurysm or other vascular lesion is seen. No increase in size of the pericholecystic hematoma. Conventional splanchnic vascular anatomy.

Case Discussion

At the time of the initial scan, the patient remained haemodynamically stable, with mild tachycardia and minimally increased oxygen requirements. She was reluctant to undergo any kind of intervention.

After consulting interventional radiology, a triple-phase angiography was performed a few hours after, to confirm possible ongoing hemorrhage, to rule out an underlying vascular pathology in the cystic artery (i.e. pseudoaneurysm), and for eventual vascular planning.

As the following cross-sectional imaging was negative for persistent bleeding or vessel anomaly, no emergency endovascular treatment was recommended. While the white cell count and CRP increased progressively, the hemoglobin remained stable above 120g/L. The patient unfortunately died of complication from sepsis shortly after imaging.

While hemorrhagic changes in the context of gangrenous cholecystitis might be undetected as masked by the clinical response to the underlying gallbladder inflammation, active bleeding is rarely captured on imaging.

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Case information

rID: 81760
Published: 26th Oct 2020
Last edited: 27th Oct 2020
Inclusion in quiz mode: Excluded
Institution: NHS Greater Glasgow and Clyde