IS Case 575: Gangrenous cholecystitis

Joseph Reis, MD

Imaging Sciences URMC

Imaging Sciences URMC 2010
Publication Date: 2011-11-17

History

Patient is a 47-year-old male presenting with waxing and waning right upper quadrant pain that radiates to his back. The patient has a past medical history of a myocardial infarction with left ventricular assist device (LVAD) placed 9 months earlier.

Findings

See Figure Legends

Discussion

Gangrenous cholecystitis is a complication of prolonged gallbladder inflammation defined pathologically by inflammatory changes of edema, vascular congestion and leukocyte infiltration in addition to one of the following: (1) Intramural hemorrhage; (2) gallbladder necrosis; or (3) microabcess formation. Patients may present with only mild symptoms of right upper quadrant pain secondary to neural death from gangrene. Risk factors include duration of untreated illness, age, male gender, cardiovascular pathology, diabetes and elevated white count of at least 15000 to 17000 wbc/mm3.

Ultrasound findings of gangrenous cholecystitis are marked by non-dependent echogenic material within the lumen, focal areas of luminal nodular proliferation, irregular fraying to the mucosal surface and asymmetric gallbladder wall edema. Focal mucosal sloughing or microabcess formation produce the nodular mucosal pattern while gallbladder empyema, hemorrhage and sloughing may comprise the non-dependent echogenic material. Asymmetry to the gallbladder wall suggests focal areas of necrosis, inflammation and hemorrhage in the submucosal layers. These imaging findings can precede macroscopic manifestations of gallbladder necrosis at surgery and can often be associated with a negative sonographic Murphy's sign as discussed above.

Imaging is essential to the diagnosis and prompt management of gangrenous gallbladder, preventing progression to perforation, sepsis and mortality.

References

  1. Rumack CM, Wilson SR, Charboneau JW. Diagnostic Ultrasound. Vol 1. 3rd Ed. St Louis, MI: Elsevier Mosby; 2005.
  2. Jeffrey RB, Laing FC, Wong W, Callen PW. Gangrenous cholecystitis: diagnosis by ultrasound. Radiology. 1983 Jul;148(1):219-21. PMID: 6856839
  3. Kumar V, Abbas AK, Fausto N. Robbins and Cotran Pathologic Basis of Disease. 7th Ed., Philadelphia, PA: Elsevier Saunders, 2005.

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