Presentation
Acute onset right upper quadrant abdominal pain after motor vehicle accident. Unremarkable history.
Patient Data
US shows dependent, layered hyperechoic material showing greater echogenicity than typical sludge.
CT shows hyperdense material within the gallbladder lumen (64HU) in NECT
Intraperitoneal free fluid in the recto-vesical pouch and surrounding the liver.
On the follow-up study, hyperdense material within the gallbladder lumen has increased in size.
The gallbladder wall is enhancing and intact.
Free fluid in the gallbladder fossa, the minor contusion of the adjacent liver is also seen.
Blood test:
RBC : 3,86 G/l ; HGB: 90 g/l
GOT: 200 U/l ; GPT: 50 U/l ; Creatinin 65 µmol/l
Ethanol : 182 mg/100ml
Case Discussion
The causes of high-density bile consist of vicarious contrast excretion, milk-of-calcium bile, gallbladder hemorrhage. The vicarious contrast excretion and milk-of-calcium bile do not generally appear as echogenic at US, nor is a fluid-fluid level observed 2. Eventually, the delayed phase CT is the clue to the diagnosis. In the traumatic gallbladder, delayed images will show an increased size of dense material within the gallbladder because the hemorrhage is progressing. In contrast, the nontraumatic gallbladder will remain stable 1.
This patient had normal renal function and no contraindication against injecting a high dose of contrast. Therefore, on the follow-up study, increased size hyperdense material within the gallbladder lumen is suggestive of progressing hemorrhage .
In the traumatic setting, US and CT findings are consistent with traumatic gallbladder hemorrhage. This case can be classified as grade II according to the AAST injury scoring scales (table 9) 3.