Contrast-enhanced ultrasonography to diagnose complicated acute cholecystitis

Gangrenous cholecystitis and perforation are severe complications of acute cholecystitis, which have a challenging preoperative diagnosis. Early identification allows better surgical management. Contrast-enhanced computed tomography (ceCT) is the current diagnostic gold standard. Contrast-enhanced ultrasonography (CEUS) is a promising tool for the diagnosis of gallbladder perforation, but data from the literature concerning efficacy are sparse. The aim of the study was to evaluate CEUS findings in pathologically proven complicated cholecystitis (gangrenous, perforated gallbladder, pericholecystic abscess). A total of 8 patients submitted to preoperative CEUS, and with subsequent proven acute complicated cholecystitis at surgical inspection and pathological analysis, were retrospectively identified. The final diagnosis was gangrenous/phlegmonous cholecystitis (n. 2), phlegmonous/ulcerative changes plus pericholecystic abscess (n. 2), perforated plus pericholecystic abscess (n. 3), or perforated plus pericholecystic biliary collection (n. 1). Conventional US findings revealed irregularly thickened gallbladder walls in all 8 patients, with vaguely defined walls in 7 patients, four of whom also had striated wall thickening. CEUS revealed irregular enhancing gallbladder walls in all patients. A distinct wall defect was seen in six patients, confirmed as gangrenous/phlegmonous cholecystitis at pathology in all six, and in four as perforation at macroscopic surgical inspection. CEUS is a non-invasive easily repeatable technique that can be performed at the bedside, and is able to accurately diagnose complicated/perforated cholecystitis. Despite the limited sample size in the present case series, CEUS appears as a promising tool for the management of patients with the clinical possibility of having an acute complicated cholecystitis.     

A Case of Gallbladder Perforation in Which the Developmental Pattern was Demonstrated by Laparoscopy

Abstract: A 58-year-old man with diabetes mellitus was referred to our clinic because of epigastric colicky pain of sudden onset with fever. An ultrasonography (US) and endoscopic ultrasonography (EUS) demonstrated marked thickening of the gallbladder wall and a pericholecystic echo-free space. A laparoscopy showed tight adhesion between the greater omenturn and the parietal peritoneum, and pooling of bile on the liver surface, the greater omenturn, and in the perisplenic area. The gallbladder itself could not be seen. A surgical laparotomy revealed perforation of the gallbladder with a pericholecystic abscess. No laparoscopic observation of free bile has been reported in cases of gallbladder perforation. In the present case, US, EUS and laparoscopy were useful for early diagnosis of gallbladder perforation. In addition, laparoscopy played an important role in determining the type of gallbladder perforation.     

Spontaneous gallbladder perforation, pericholecystic abscess and cholecystoduodenal fistula as the first manifestations of gallstone disease

BACKGROUND:Gallstone disease is common,and complications that are frequently encountered include acute cholecystitis and acute pancreatitis,but rarely gallbladder perforation. METHOD:Data were retrospectively collected from clinical case notes and a literature review is presented. RESULTS:A 72-year-old lady presented with spontaneous gallbladder perforation,pericholecystic abscess and cholecystoduodenal fistula as the first manifestations of gallstone disease.She was previously well and had no abdominal com...     

Omental and extraperitoneal abscesses complicating cholecystocolic fistula

BackgroundAcute cholecystitis resolves with conservative treatment in most patients, but empyema or perforation of an ischaemic area may develop, resulting in a pericholecystic abscess, bile peritonitis or a cholecysto-enteric fistula.Case outlineA 63-year-old man presented with extraperitoneal and omental abscess formation complicating a cholecystocolic fistula secondary to gallbladder disease. Histological examination of the gallbladder and omentum showed xanthogranulomatous inflammation.ConclusionA detailed literature review failed to demonstrate a previous report of this combination of rare complications of gallbladder disease.     

Ultrasonographic findings in acute acalculous cholecystitis

Acute acalculous cholecystitis (AAC) is usually seen as a complication of major surgery or trauma. Although this entity is well-known in the surgical literature, little has been written about it in the radiologic literature. A review of patient records from 1975 through 1982 revealed 16 patients with pathologically confirmed AAC on whom at least 1 sonographic study had been performed. Thickening of the gallbladder wall, a subserosal "halo" of edema, pericholecystic abscess, and marked gallbladder distention were consistent findings in AAC. In the proper clinical setting, these otherwise nonspecific findings allow a prompt and accurate diagnosis.     

Xanthogranulomatous cholecystitis mimicking gallbladder carcinoma with a false-positive result on fluorodeoxyglucose PET

Recently, several reports have demonstrated that fluorine-18 fluorodeoxyglucose positron emission tomography （FDG-PET） is useful in differentiating between benign and malignant lesions in the gallbladder. However, there is a limitation in the ability of FDG-PET to differentiate between inflammatory and malignant lesions. We herein present a case of xanthogranulomatous cholecystitis misdiagnosed as gallbladder carcinoma by ultrasonography and computed tomography. FDG-PET also showed increased activity. In this case, FDG-PET findings resulted in a false-positive for the diagnosis of gallbladder carcinoma.     

The significance of magnetic resonance cholangiopancreatography in acute cholecystitis]

To clarify the significance of magnetic renonance cholangiopancreatography (MRCP) in the acute phase of acute cholecystitis, MRCP was carried out in forty-five patients with acute cholecystitis in their acute phase. The MR pericholecystic high signal was observed in 38 of the 45 patients (84%). Enlargement of the gallbladder, presence of gallstones, and impacted stones was seen in 71%, 53%, and 18%, respectively. The MR pericholecystic high signal was classified into four categories: type 0, not observed; type 1, a liner high signal; type 2, a band-like high signal; type 3, a radiating high signal. In patients who showed a type 3 MR pericholecystic high signal, 91% required percutaneous transhepatic gallbladder drainage, and most of the gallbladders were diagnosed as necrotic cholecystitis by histology. The accuracy of MRCP for the diagnosis of choledocholithiasis was 96%. It was suggested that MRCP for patients with acute cholecystitis in the acute phase provides useful information for planning the treatment.     

Xanthogranulomatous cholecystitis expressing high levels of DUPAN-II

We report a case of xanthogranulomatous cholecystitis (XGC) showing high levels of serum DUPAN-II in a 65-year-old woman. Preoperative radiologic examination showed no abnormal findings except in the gallbladder. Endoscopic ultrasonography was effective for differentiating chronic cholecystitis from gallbladder cancer before the operation. Cholecystectomy was performed by laparotomy, and the diagnosis of XGC was confirmed intraoperatively by examining a frozen section. Histologically, no cancer lesion was observed in the gallbladder, while immunochemical reactivity to DUPAN-II was demonstrated in the brush-border area of the epithelium and in histiocytes in the gallbladder. The half-life of serum DUPAN-II in our patient after cholecystectomy was approximately 1 month, and finally dropped to within the normal range after cholecystectomy.     

A case of early cystic duct carcinoma concomitant with xanthogranulomatous cholecystitis (XGC)

We reported a case of early cystic duct carcinoma concomitant with xanthogranulomatous cholecystitis (XGC). This case was a 72-year-old man in whom thickening of the gallbladder wall was pointed out an abdominal ultrasonography and elevation of the CA19-9 level was detected at a local clinic. Endoscopic ultrasonography and CT demonstrated a mass in the cystic duct. Mapping biopsy using peroral cholangioscopy (POCS) revealed a diagnosis of cystic carcinoma with superficial flat growth, therefore a pylorus-preserving pancreatoduodenectomy was performed. Histopathological diagnosis was well differentiated papillotubular adenocarcinoma with superficial flat spread and the thickening of the gallbladder wall was XGC. A case of early cystic duct carcinoma concomitant with XGC is extremely rare.     

Localized wall thickening of the gallbladder mimicking a neoplasm

Clinical diagnosis of chronic cholecystitis is made based on diffuse hyperechoic thickening of the gallbladder wall as shown by ultrasonographic examination. We herein report three cases of chronic cholecystitis showing localized hypoechoic thickening of the gallbladder wall that mimicked gallbladder cancer by ultrasonography. Histologically, hypertrophy of the muscularis propria was a common characteristic finding in these three patients. A smooth surface of the inner hypoechoic layer of the thickened wall was considered to be a reliable finding in the differential diagnosis between this type of chronic cholecystitis and gallbladder cancer.     

Computed tomography as an adjunct to ultrasound in the diagnosis of acute acalculous cholecystitis

The sonographic and computed tomographic (CT) findings were reviewed in 17 patients with acute acalculous cholecystitis (AAC) over a 6-year period from 1984 to 1989. Of the six patients in whom both ultrasound and CT were performed, CT revealed marked gallbladder (GB) wall abnormalities, including perforation, and pericholecystic fluid collections in five patients not demonstrated by sonography. Of the total group, five patients had GB wall thicknesses of less than or equal to 3 mm (normal) at pathologic examination, which demonstrated a spectrum of disease ranging from acute hemorrhagic/necrotizing, to gangrenous acalculous cholecystitis with perforation. Sonography was falsely negative or significantly underestimated the severity of AAC in seven of the 13 patients examined by sonography. CT because of its superior ability to assess pericholecystic inflammation may provide additional diagnostic information even after a thorough sonographic study in cases of AAC.     

Xanthogranulomatous cholecystitis mimicking stage IV gallbladder cancer

Patients with xanthogranulomatous cholecystitis often undergo excessive surgical resections because of difficulty in distinguishing their condition from gallbladder cancer. Herein we present a patient with xanthogranulomatous cholecystitis mimicking stage IVA gallbladder cancer who underwent a hepatopancreatoduodenectomy. The 64-year-old man was admitted to the local hospital with a chief complaint of high fever, hypochondrolgia and jaundice. One month later, he transferred to Tsukuba University Hospital with a hard palpable fixed large tumor in the right hypochondrium. Computed tomography and ultrasonography showed a tumor originating from the gallbladder extending to the adjacent liver parenchyma, as well as nodes in the hepatoduodenal ligaments approaching the head of the pancreas. Endoscopic retrograde cholangiopancreatography failed to exhibit the gallbladder despite the visualization of irregular narrowing of the common hepatic duct. Angiography demonstrated encasement of the right hepatic artery and narrowing of the right portal vein. On the other hand, the level of serum carbohydrate antigen 19-9 was within normal range. Based on those findings, a right hepatic lobectomy with pancreaticoduodenectomy was conducted under the preoperative and intraoperative diagnosis of gallbladder cancer; stage IVA. The gross findings of the surgical specimen showed an ill-defined yellowish hard mass, but microscopic examination demonstrated xanthogranulomatous cholecystitis. The presented case shows that xanthogranulomatous cholecystitis can mimic an advanced gallbladder carcinoma when the severe chronic inflammatory changes have extended to the liver hilum down to the head of the pancreas. However, the normal level of tumor markers in all clinical courses might be a reason to consider xanthogranulomatous cholecystitis instead of gallbladder cancer. Even when the correct diagnosis is made, the possibility that the adjacent organs should be resected is not remote.     

Unruptured cystic artery pseudoaneurysm accompanied by Mirizzi syndrome: a report of a case

Pseudoaneurysm of the cystic artery is a rare complication of cholecystitis. 34 cases have been reported from 1976 to 2012, searched on MEDLINE and most of the cases have presented with gastrointestinal bleeding. We report the third case of an unruptured pseudoaneurysm of the cystic artery associated with calculous cholecystitis. An 85-year-old female presented to the emergency unit with epigastric pain and jaundice. Laboratory data and contrast-enhanced computed tomography (CT) revealed calculous cholecystitis and Mirizzi syndrome accompanied by a pseudoaneurysm in the gallbladder. Color Doppler ultrasonography (US) clearly demonstrated the pulsatile pseudoaneurysm. After biliary drainage and antimicrobial therapy, selective hepatic angiography with the aim of providing transcatheter arterial embolization was performed but the pseudoaneurysm had already thrombosed spontaneously. Open cholecystectomy was successfully carried out. Histological specimens demonstrated the pseudoaneurysm with organized thrombus in the epithelial wall of the gallbladder thickened with severe fibrosis. It is suggested that cholecystitis with unusual symptoms such as gastrointestinal bleeding requires immediate enhanced CT and US with Doppler imaging in order not to overlook a rare but life-threatening pseudoaneurysm.     

Post-stress nonlithiasic acute cholecystitis. Contribution of ultrasonics to the diagnosis and treatment in 50 cases

Fifty cases of post-stress acute acalculous cholecystitis were observed during the past 9 years, mainly after major surgery or trauma. The apparently increasing incidence over the last 4 years (42 cases) could probably be explained by a better diagnostic approach of this condition by routine use of ultrasonography. No specific etiological factor could be found; however total parenteral nutrition and/or sepsis and/or use of narcotics could possibly play a role in the appearance of this complication. Although diagnosis can occasionally be suspected in the basis of abdominal and infectious signs, diagnosis was made primarily on the following ultrasonographic signs: enlarged gallbladder with thickened wall, sludge, and occasionally a double-wall aspect and a pericholecystic collection. In this series, most of the patients were treated by cholecystectomy, but a new therapeutic approach was used in 10 cases: percutaneous transhepatic drainage under sonographic control. Outcome is still poor, with a 50 p. 100 mortality rate.     

Gallbladder torsion: case report and review of 245 cases reported in the Japanese literature

We report here a case of torsion of the gallbladder in a 73-year-old woman. The patient was admitted to our hospital with right hypochondralgia. Ultrasonography and computed tomography demonstrated a distended gallbladder, with a multilayered wall, which contained no stones. Since the symptoms did not respond to antibiotics, laparotomy was performed. The gallbladder was found to be twisted around its pedicle and to be gangrenous. Cholecystectomy was performed, and the patient had an uneventful postoperative course. We also reviewed 245 cases reported in the Japanese literature. The clinical features of gallbladder torsion, which include low frequency of fever and jaundice, poor response to antibiotic therapy, and acute onset of abdominal pain, may be helpful in the differential diagnosis from acute cholecystitis. Moreover, a highly suggestive sign of gallbladder torsion observed by ultrasonography or computed tomography is a markedly enlarged “floating” gallbladder with a continuous hypoechoic line indicating edematous change in the wall.     

Le volvulus de la vésicule biliaire : une cause rare de cholécystite aiguë. A propos d’un cas

The gallbladder volvulus is a rare disease, preoperative diagnosis is very difficult, it is a disease whose prognosis depends on early diagnosis and treatment. The Computed tomography seems most contributory to preoperative diagnosis. The therapeutic management is often surgical and cholecystectomy should be carried out immediately to prevent progression to gangrene and perforation of the gallbladder responsible for an often fatal biliary peritonitis Our message through this work is that it should never adopt an exclusive medical treatment with antibiotics in case of acute acalculous cholecystitis in an elderly patient before eliminating a volvulus of the gallbladder. We report the case of gallbladder volvulus diagnosed preoperatively by CT and we discuss diagnostic aspects and therapeutic implications, while stressing the importance of the scanner in the preoperative diagnosis.     

Experience with 1904 laparoscopic cholecystectomies at a private hospital

The purpose of this paper is to describe our recent experience in performing laparoscopic cholecystectomies of which we performed 1904, from January 1991 to May 1997, at our private hospital, mainly to treat cholecystolithiasis. The patients included 1563 with gallbladder stones (82.0%), 82 with cholecystocholedocholithiasis (4.3%), 104 with adenomyomatosis (5.5%), 132 with polyps (6.9%), and 23 with gallbladder cancer (1.3%). A difficult pericholecystic dissection led to conversion to open surgery in 61 patients. The average operation time was 63 min. Bile duct injury or cystic artery bleeding occurred in 3 patients with acute cholecystitis, and small intestine injury occurred in 1 patient, while bile leakage or a right subphrenic abscess occurred in 6 patients postoperatively. Although this series included 69 patients with previous upper abdominal surgery, 14 with liver cirrhosis, 267 with a nonvisualized gallbladder, and 148 with acute cholecystitis, the overall conversion rate was only 3.2% and morbidity only 0.5%. Although almost all patients with cholelithiasis are now considered potential candidates for a laparoscopic cholecystectomy, difficulties during cholecystectomy have been encountered in patients with acute cholecystitis. Surgeons should thus be fully prepared to convert to open surgery whenever difficulties are encountered, in order to avoid complication.     

Preoperative diagnosis of gallbladder torsion by magnetic resonance cholangiopancreatography

The patient was a 78-year-old woman who was diagnosed as having gallbladder torsion preoperatively. This is the first reported case diagnosed by magnetic resonance cholangiopancreatography (MRCP). Signs and symptoms of this condition are often subtle. Radiologic evaluation by ultrasonography and computed tomography (CT) showed acute cholecystitis with stone. Drip-infusion cholangiography CT failed to outline the gallbladder, and distortion of the extrahepatic bile ducts and interruption of the cystic duct were observed. MRCP showed 1) a v-shaped distortion of the extrahepatic bile ducts due to traction by the cystic duct, 2) tapering and twisting interruption of the cystic duct, 3) a distended and enlarged gallbladder that was deviated to the midline of the abdomen, and 4) a difference in intensity between the gallbladder and the extrahepatic bile ducts and the cystic duct. A definitive diagnosis of gallbladder torsion (volvulus) was made by MRCP preoperatively. If treated surgically, gallbladder detorsion before cholecystectomy is a helpful technique to avoid bile duct injury. This condition should be suspected in elderly women with acute cholecystitis or acute abdominal pain of unknown origin, and MRCP may be very useful in making a definitive diagnosis.     

Preoperative Diagnosis of Gallbladder Torsion by Magnetic Resonance Cholangiopancreatography

The patient was a 78-year-old woman who was diagnosed as having gallbladder torsion preoperatively. This is the first reported case diagnosed by magnetic resonance cholangiopancreatography (MRCP). Signs and symptoms of this condition are often subtle. Radiologic evaluation by ultrasonography and computed tomography (CT) showed acute cholecystitis with stone. Drip-infusion cholangiography CT failed to outline the gallbladder, and distortion of the extrahepatic bile ducts and interruption of the cystic duct were observed. MRCP showed 1) a v-shaped distortion of the extrahepatic bile ducts due to traction by the cystic duct, 2) tapering and twisting interruption of the cystic duct, 3) a distended and enlarged gallbladder that was deviated to the midline of the abdomen, and 4) a difference in intensity between the gallbladder and the extrahepatic bile ducts and the cystic duct. A definitive diagnosis of gallbladder torsion (volvulus) was made by MRCP preoperatively. If treated surgically, gallbladder detorsion before cholecystectomy is a helpful technique to avoid bile duct injury. This condition should be suspected in elderly women with acute cholecystitis or acute abdominal pain of unknown origin, and MRCP may be very useful in making a definitive diagnosis.     

胆囊周围脓肿的超声表现

目的探讨超声影像技术在胆囊周围脓肿（简称囊周脓肿）诊断中的价值。方法使用彩色多普勒超声诊断仪,对经临床证实的囊周脓肿的63例行各种切面扫查。详细观察胆囊炎性改变情况,囊周脓肿的大小、形态、范围及回声情况,脓肿与毗邻组织脏器间的关系等,将异常所见摄片记录。结果 63例中接受手术治疗45例,术中发现与囊周组织均有不同程度的粘连。囊周脓肿术前超声诊断与手术所见基本符合率100%（34/34）,脓肿对囊周组织器官的炎性粘连、包裹,超声判定与术后诊断基本符合率为82.35%（28/34）。结论超声对囊周脓肿具有较高诊断价值。