Gallbladder Explosion

Authored by Sandi Chen, and Mario Corro Reviewed by SIUH Sono Division

85 year old female with history of HTN and hypothyroidism presents to ED for epigastric pain that started a week ago. Pain is postprandial, moderate in intensity, stabbing, continuous and radiating to the RUQ. Associated with nausea but no vomiting. Currently denies abdominal pain but complains of nausea. She denies any fever, chills, constipation or diarrhea. The following images were obtained.

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Questions:

 

1. What is seen on the above ultrasound image?

 

2. What disease processes could lead to this ultrasound finding?

 

3.  What are the ultrasound criteria for cholelithiasis? 

 

4. What are  sonographic findings in acute cholecystitis? 

 

5. What complications can arise if the above condition is not treated?

 

Answers:

  1. Gallbladder perforation (yellow arrow)

    1. Pericholecystic fluid and 

    2. True gallbladder lumen filled with stones and sludge (red arrow)

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2. Gallbladder perforation is most commonly due to occlusion of the cystic duct by gallstone and subsequent retention of contents. The associated rise in luminal pressure limits venous and lymphatic drainage, leading to vascular compromise, necrosis, and ultimately perforation. May also arise due to laparoscopic cholecystectomy.

 3. Cholelithiasis (blue arrow): highly reflective echogenic focus within gallbladder lumen, normally with posterior acoustic shadowing. Stones will also show gravity-dependent movement.

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4.Cholecystitis:   * = most sensitive

    1. Presence of ultrasonic Murphy sign*

    2. Gallstones visualized, especially if in gallbladder neck*

    3. Anterior gallbladder wall thickening >3mm

    4. Presence of pericholecystic fluid

    5. Hydrops (>5x10cm)

(None of the above signs are pathognomonic)

5.Pericholecystic abscess, cholecystoenteric or cholecystobiliary fistula formation, bile peritonitis, pancreatitis, subphrenic or hepatic abscess formation