Perforated cholecystitis

Case contributed by Dr Paul Simkin

Presentation

Jaundice and fever. Presented 4 days after onset of pain.

Patient Data

Age: 55
Gender: Male
CT

The gallbladder is thickwalled, with significant surrounding fat stranding consistent with inflammation. Near the fundus of the gallbladder the wall is non-enhancing/non-visualised, concerning for perforation. There is a moderate amount of pericholecystic free fluid. Hypodensity within the adjacent liver is concerning for early hepatic abscess formation. No radiopaque stone is demonstrated. No gross intra or extra hepatic duct dilation.

A trace of intra-abdominal free fluid is seen down the right paracolic gutter and in the pelvis. No pneumoperitoneum.

Conclusion:

The appearance is consistent with acute cholecystitis, and highly concerning for perforation and early hepatic abscess formation.

The general surgical registrar on call was notified of the findings at 15:40 hours.

CT

Follow up CT after cholecystotomy.

A percutaneous catheter has been inserted into the gallbladder via a transhepatic approach, traversing segment V of the liver. The tip of the catheter is in the gallbladder body. The previously distended gallbladder is now predominantly collapsed. Fluid and gas in the gallbladder fossa are consistent with expected post-procedural change. No hepatic haematoma detected within the limits of a non-contrast study.

Conclusion:

Post-cholecystostomy CT demonstrates good catheter position with no complications identified.

Fluoroscopy

Catheter choleangiogram

Tubogram

Under fluoroscopic guidance, Omnipaque 240 was injected via the cholecystostomy which remains in situ in the gallbladder lumen. The gallbladder opacified with no filling defects detected. Mural irregularity of the gallbladder is consistent with known cholecystitis. Delayed images demonstrated contrast extravasation from the body of the gallbladder in keeping with perforation. The cystic duct opacified normally. After some delay, contrast entered the common bile duct and duodenum. The common bile and common hepatic ducts opacified normally throughout with no filling defects evident. No intrahepatic or extrahepatic biliary dilatation. Note is made of contrast filling the periampullary duodenal diverticulum demonstrated on CT. The procedure was performed under sterile technique.

Conclusion:

No biliary dilatation or evidence of choledocholithiasis or other source of biliary obstruction. Gallbladder mural irregularity is consistent with known cholecystitis complicated by perforation.

PlayAdd to Share

Case information

rID: 32823
Case created: 17th Dec 2014
Last edited: 12th Sep 2016
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.