IS Case 575: Gangrenous cholecystitis
Imaging Sciences URMC 2010
Publication Date: 2011-11-17
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.
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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.
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