Presentation
Weight loss, obstructive jaundice, fever and RUQ pain
Patient Data
Mild to moderate intrahepatic bile duct dilatation. The entire CBD shows occlusion with hypoechoic structures along its entire course.
The gallbladder is enlarged with thickened wall encroaching upon it lumen with multiple hypoechoic areas. The wall shows ill-defined areas with surrounding hypoechoic gallbladder hepatic bed, likely edematous. It is contracted over two stones one intraluminal and the other is impacted at its neck.
The gall bladder is distended (5.5 cm in transverse diameter) with an obstructing stone at its neck. The mucosal line is irregular with multiple defects and multiple intramural abscesses showing evident diffusion restriction. Mild pericholecystic edema and minimal fluid are seen. No extramural or intra-hepatic perforation.
Marked dilatation of both extra and intrahepatic ducts (CBD= 18 mm).
Multiple CBD stones, reaching 15 mm. Internal plastic stent is noted. Smaller stones are noted in both main biliary ducts.
Case Discussion
This case shows enlarged obstructed gallbladder with features of acute calculous cholecystitis with intramural abscesses, suggested by the presence of marked diffusion restriction. Features raise the possibility of xanthogranulomatous cholecystitis secondary to chronic obstruction.
The case also shows choledocholithiasis and marked upstream biliary dilatation by multiple intraluminal CBD stones, which is the cause of the patient's presentation with obstructive jaundice.
The differentiation between malignant versus benign mural thickening based on DWI imaging is difficult and DWI findings should be interpreted in conjunction with standard MRI sequences. Benign mural thickening is usually smooth and diffuse with preserved mucosal contour, unlike the solid and asymmetric thickening of tumors.
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