Presentation: 65 year-old female presenting with severe right upper quadrant pain.
Key findings:
Diagnosis: Severe gangrenous cholecystitis.
Management: Surgical.
Comment: This diagnosis could also be made with ultrasound. In general, US and CT play a complimentary role in diagnosing acute cholecystitis. US can help by showing gallstones and informing of a sonographic Murphy's sign. CT is better at showing inflammation surrounding the gallbladder.
Operative note:
"There were dense adhesions from the omentum to the fundus of the gallbladder and the liver edge. There were dense adhesions from the right transverse mesocolon to the fundus of the gallbladder. The gallbladder was essentially encased in adhesions. It was necessary to utilize blunt dissection as well as dissection with the harmonic scalpel to mobilize the omental and right transverse mesocolon adhesions away from the gallbladder. The dissection was very difficult and tedious. Ultimately, it was possible to expose the cystic duct. The cystic duct was encased in inflammation. A hemoclip was placed at the junction of the cystic duct and the neck of the gallbladder. The cystic artery was divided between a hemoclip proximally and a standard clip distally and divided in order to facilitate cholangiogram. A transverse ductotomy was created. A cholangiocatheter was passed percutaneously with difficulty and secured with a clip. Cholangiogram was obtained. Initially, it appeared that the gallbladder filled retrograde past the hemoclip through a cystic duct remnant. When that was divided, the gallbladder no longer filled. The common and hepatic ducts did appear to be mildly dilated. There were no filling defects. There was possible contrast into the duodenum. The cholangiocatheter was removed. The cystic duct was then secured with clips. The gallbladder was then essentially obliterated. There was really no well-defined gallbladder wall or lumen.With that in mind, the dissection was carried along the liver bed. A single approximately 1.6 cm black-green gallstone was found and was retrieved along with the gallbladder and placed in an EndoCatch. It did appear as if all of the gallbladder wall had been removed, but there was marked inflammation of the liver bed; thus, the liver bed was cauterized in order to obliterate any residual mucosa. Subsequently, because there was some oozing from the liver edges, some Arista was placed in the bed of the gallbladder. Because there was potential for bile leak due to the difficulty of the dissection (bile leak duct of Luschka), because of the difficulty and depth of the resection, a round closed suction drain was placed in the gallbladder fossa and run out to the most inferior right subcostal trochar site. That drain was sutured in place with nylon. It was placed in bulb suction."
Pathology report:
TISSUES: GALLBLADDER - GALLBLADDER
GROSS: Received in formalin labeled gallbladder is a 6 x 2.5 x 2.0 cm previously opened gallbladder. Also within the container is a 1.0 cm round green stone. The serosa is somewhat rough. The mucosa is hemorrhagic. The cystic duct is patent. The wall measures up to 0.5 cm.
MICROSCOPIC: Mucosa is eroded. The muscularis is hypertrophic. The wall is expanded by fibrosis and a marked mixed inflammatory cell infiltrate.
Discussion:
Very severe gangrenous cholecystitis, resulting in ischemic necrosis of the gallbladder wall. This is more common in elderly patients. Patient was temporized with percutaneous cholecystostomy tube in order to improve surgical success.
The key imaging featuring differentiating acute uncomplicated cholecystitis from gangrenous cholecystitis are: