Gangrenous cholecystitis: diagnosis by ultrasound

Traveling gallstones: review of MR imaging and surgical pathology features of gallstone disease and its complications in the gallbladder and beyond

Gallstone-related disease comprises a spectrum of conditions resulting from biliary stone formation, leading to obstruction and inflammatory complications. These can significantly impact patient quality of life and carry high morbidity if not accurately detected. Appropriate imaging is essential for evaluating the extent of gallstone disease and assuring appropriate clinical management. Magnetic Resonance Imaging (MRI) techniques (including Magnetic Resonance Cholangiopancreatography (MRCP) are increasingly used for diagnosis of gallstone disease and its complications and provide high contrast resolution and facilitate tissue-level assessment of gallstone disease processes. In this review we seek to delve deep into the spectrum of MR imaging in diagnose of gallstone-related disease within the gallbladder and complications related to migration of the gallstones to the gall bladder neck or cystic duct, common hepatic duct or bile duct (choledocholithiasis) and beyond, including gallstone pancreatitis, gallstone ileus, Bouveret syndrome, and dropped gallstones, by offering key examples from our practice. Furthermore, we will specifically highlight the crucial role of MRI and MRCP for enhancing diagnostic accuracy and improving patient outcomes in gallstone-related disease and showcase relevant surgical pathology specimens of various gallstone related complications.

Evaluation of early sonographic predictors of gangrenous cholecystitis: mucosal discontinuity and echogenic pericholecystic fat

PURPOSE

To identify early sonographic features of gangrenous cholecystitis.

MATERIALS AND METHODS

101 patients with acute cholecystitis and a pre-operative sonogram were retrospectively reviewed by three radiologists in this IRB-approved and HIPAA-compliant study. Imaging data were correlated with histologic findings and compared using the Fisher's exact test or Student t test with p < 0.05 to determine statistical significance.

RESULTS

Forty-eight patients had gangrenous cholecystitis and 53 had non-gangrenous acute cholecystitis. Patients with gangrenous cholecystitis tended to be older (67 ± 17 vs 48 ± 18 years; p = 0.0001), male (ratio of male:female 2:1 vs 0.6:1; p = 0.005), tachycardic (60% vs 28%; p = 0.001), and diabetic (25% vs 8%; p = 0.001). Median time between pre-operative sonogram and surgery was 1 day. On imaging, patients with gangrenous cholecystitis were more likely to have echogenic pericholecystic fat (p = 0.001), mucosal discontinuity (p = 0.010), and frank perforation (p = 0.004), while no statistically significant differences were seen in the presence of sloughed mucosa (p = 0.104), pericholecystic fluid (p = 0.523) or wall striations (p = 0.839). In patients with gangrenous cholecystitis and echogenic pericholecystic fat, a smaller subset had concurrent mucosal discontinuity (57%), and a smaller subset of those had concurrent frank perforation (58%). The positive likelihood ratios for gangrenous cholecystitis with echogenic fat and mucosal discontinuity were 4.6 (95% confidence interval 1.9-11.3) and 14.4 (2.0-106), respectively.

CONCLUSION

Echogenic pericholecystic fat and mucosal discontinuity are early sonographic findings that may help identify gangrenous cholecystitis prior to late findings of frank perforation.

B-mode ultrasonographic diagnosis in gallbladder wall thickening

Diseases associated with gallbladder wall thickening include benign entities such as adenomyomatosis of the gallbladder, acute and chronic cholecystitis, and hyperplasia associated with pancreaticobiliary maljunction, and also cancer. Unique conditions such as sclerosing cholecystitis and cholecystitis associated with immune checkpoint inhibitor treatment can also manifest as wall thickening, as in some systemic inflammatory conditions. Gallbladder cancer, the most serious disease that can show wall thickening, can be difficult to diagnose early and to distinguish from benign causes of wall thickening, contributing to a poor prognosis. Differentiating between xanthogranulomatous cholecystitis and gallbladder cancer with wall thickening can be particularly problematic. Cancers that thicken the wall while coexisting with benign lesions that cause wall thickening represent another potential pitfall. In contrast, some benign gallbladder lesions that can cause wall thickening, such as adenomyomatosis and acute cholecystitis, typically show characteristic ultrasonographic features that, together with clinical findings, permit easier diagnosis. In this review of the literature, we describe B-mode abdominal ultrasonographic diagnosis of gallbladder lesions showing wall thickening.

Imaging of Acute Hepatobiliary Dysfunction

Abdominal pain is a common cause for emergency department visits in the United States, and biliary tract disease is the fifth most common cause of hospital admission. Common causes of acute hepatobiliary include gallstones and its associated complications and multiple other hepatobiliary etiologies, including infectious, inflammatory, vascular, and neoplastic causes. Postoperative complications of the biliary tract can result in an acute abdomen. Imaging of the hepatobiliary tree is integral in the diagnostic evaluation of acute hepatobiliary dysfunction, and imaging of the biliary tree requires a multimodality approach utilizing ultrasound, computed tomography, nuclear medicine, and MR imaging.

A deceptive case of emphysematous cholecystitis complicated with retroperitoneal gangrene and emphysematous pancreatitis: clinical and computed tomography features

Purpose

Emphysematous cholecystitis (EC) is an uncommon, severe variant of acute cholecystitis caused by gas- forming bacteria – most often Clostridium perfringens and Escherichia coli. We present a deceptive case of EC associated with retroperitoneal gas gangrene and emphysematous pancreatitis.

Case report

An 86-year-old, overweight woman was admitted to the emergency department with non-specific abdominal symptoms. Admission laboratory tests showed elevated diastase levels indicating acute pancreatitis. Computed tomography (CT) demonstrated a substantial amount of gas in the retroperitoneum and peritoneal cavity, which raised a suspicion of duodenal perforation. Primary diagnosis was not confirmed during emergency laparotomy, which revealed a gangrenous gallbladder adjacent to the duodenum and surrounded by purulent fluid. The final diagnosis established after laparotomy and rereading of CT scans was that of emphysematous cholecystitis associated with gangrenous pancreatitis and retroperitoneal gangrene. After surgery, the patient was transferred to the intensive care unit in septic shock. Shortly after, the second laparotomy was undertaken on suspicion of internal bleeding. During surgery, the patient experienced cardiac arrest and died despite immediate resuscitation.

Conclusions

Emphysematous cholecystitis may be associated with a spread of infection both to the peritoneal cavity and retroperitoneum and result in a substantial amount of gas in those anatomic compartments. The knowledge of this rare complication may be helpful in establishing a correct diagnosis.

Sonography of Acute Cholecystitis and Its Mimics

Right upper quadrant (RUQ) abdominal pain is a common complaint. Acute cholecystitis (AC) is the primary diagnostic consideration in most adults presenting with acute onset RUQ abdominal pain; however, a variety of other conditions can mimic AC. Abdominal ultrasound (US) receives the highest score for imaging appropriateness for these patients. This article reviews the sonographic findings of uncomplicated and complicated AC and provides practical technical tips. The radiologist should be familiar with conditions that can mimic AC, be able to suggest these alternative diagnoses when findings are present on US, and recommend additional tests or procedures, if needed.

Fingerprinting Acute Digestive Diseases by Untargeted NMR Based Metabolomics

Precision medicine may significantly contribute to rapid disease diagnosis and targeted therapy, but relies on the availability of detailed, subject specific, clinical information. Proton nuclear magnetic resonance (¹H–NMR) spectroscopy of body fluids can extract individual metabolic fingerprints. Herein, we studied 64 patients admitted to the Florence main hospital emergency room with severe abdominal pain. A blood sample was drawn from each patient at admission, and the corresponding sera underwent ¹H–NMR metabolomics fingerprinting. Unsupervised Principal Component Analysis (PCA) analysis showed a significant discrimination between a group of patients with symptoms of upper abdominal pain and a second group consisting of patients with diffuse abdominal/intestinal pain. Prompted by this observation, supervised statistical analysis (Orthogonal Partial Least Squares–Discriminant Analysis (OPLS-DA)) showed a very good discrimination (>90%) between the two groups of symptoms. This is a surprising finding, given that neither of the two symptoms points directly to a specific disease among those studied here. Actually herein, upper abdominal pain may result from either symptomatic gallstones, cholecystitis, or pancreatitis, while diffuse abdominal/intestinal pain may result from either intestinal ischemia, strangulated obstruction, or mechanical obstruction. Although limited by the small number of samples from each of these six conditions, discrimination of these diseases was attempted. In the first symptom group, >70% discrimination accuracy was obtained among symptomatic gallstones, pancreatitis, and cholecystitis, while for the second symptom group >85% classification accuracy was obtained for intestinal ischemia, strangulated obstruction, and mechanical obstruction. No single metabolite stands up as a possible biomarker for any of these diseases, while the contribution of the whole ¹H–NMR serum fingerprint seems to be a promising candidate, to be confirmed on larger cohorts, as a first-line discriminator for these diseases.

[Acute acalculous gangrenous cholecystitis in postoperative period after orthopedic surgery: about a case]

La cholécystite gangreneuse alithiasique postopératoire est une complication grave et sévère, surtout chez les malades hospitalisés en réanimation. Elle survient le plus souvent au décours d'une chirurgie vasculaire ou digestive majeure, d'un polytraumatisme, dans un contexte septique ou dans un contexte de choc. Nous rapportons l'observation d'un homme âgé de 74 ans opéré d'une fracture du col du fémur, au sixième jour postopératoire il a développé un tableau clinique d'une cholécystite aigue dont les explorations radiologiques ont confirmé son caractère alithiasique. Après une cholécystectomie en urgence, l'étude anatomopathologique a conclu à une cholécystite gangreneuse alithiasique.

Impact of scheduled laparoscopic cholecystectomy in patients with acute cholecystitis, following percutaneous transhepatic gallbladder drainage

Backgrounds/Aims

Frequently encountered in practice, the first-line treatment for acute cholecystitis is early or urgent cholecystectomy, with laparoscopic cholecystectomy (LC) being the preferred method. Percutaneous transhepatic gallbladder drainage (PTGBD) is considered as a safe alternative therapeutic option for resolving acute cholecystitis in surgically high-risk patients. We evaluated the surgical outcomes of acute cholecystitis, focusing on the differences between emergent LC without PTGBD, and scheduled LC following PTGBD.

Methods

Between March 2010 and December 2014, 294 patients with acute cholecystitis who had undergone LC, were retrospectively studied. Group I included 166 patients who underwent emergency LC without PTGBD. Group II included 128 patients who underwent scheduled LC after PTGBD. Clinical outcomes were analyzed according to each group.

Results

On admission, Group II had a higher mean level of c-reactive protein than Group I. According to the classification of the American Society of Anesthesiologists (ASA), group II had a greater number of high-risk patients than group I. There was no significant difference on perioperative outcomes between the two groups, including open conversion rate and complications. Analysis as per the ASA classes revealed no statistically remarkable finding between the groups.

Conclusions

There are no significant differences in the surgical outcomes of emergency LC group without PTGBD, and scheduled LC group following PTGBD. Comparison between two groups according to ASA classification reflecting the comorbidity and severity of condition of the patients also revealed no significant differences. However, scheduled LC following PTGBD is important for patients having acute cholecystitis with concurrent comorbidity.

Ultrasonography in Acute Gallbladder Perforation

The files of patients with acute cholecystitis from two large university hospitals from the years 1978–1985 were employed to find the cases with acute gallbladder perforation for this study. Only those patients (n=9) were selected for the analysis of sonographic signs of acute gallbladder perforation who had less than 48 hours of symptoms before sonography, and were operated upon within 24 hours of the sonography. Patients (n=10) with non-complicated acute cholecystitis and identical in regard to the duration of the symptoms and the timing of the sonography and the operation formed a control group. The sonographic findings in patients with gallbladder perforation were pericholecystic fluid collections, free peritoneal fluid, disappearance of the gallbladder wall echoes, focal highly echogenic areas with acoustic shadows in the gallbladder, and an inhomogeneous, generally echo-poor gallbladder wall.

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.

Sonographic Diagnosis of Complicated Cholecystitis

OBJECTIVES

Early detection of the complications of cholecystitis is important for clinical management, yet only a small percentage of patients have a correct diagnosis before surgery. The purpose of our study was to identify sonographic findings that are associated with complicated cholecystitis.

METHODS

Sonographic, surgical, and pathologic reports were reviewed for 70 patients who underwent early cholecystectomies from January 2010 to August 2014. Sonograms were assessed for 16 independent variables. Statistical analyses were performed to evaluate associations between various sonographic features and complicated cholecystitis.

RESULTS

Sonographic signs associated with complicated cholecystitis (P< .05) were a greater short-axis gallbladder diameter (mean, 4.4 versus 4.0 cm), a greater mean wall thickness (5.6 versus 4.2 mm), and the likelihood of wall striations, gallbladder echogenic content, pericholecystic free fluid, and local inflammatory fat changes. Specific sonographic signs, such as sloughed intraluminal membranes, were detected in a small percentage of cases (10%). None of the sonographic features evaluated in this study was found to be sensitive and specific enough to indicate complicated cholecystitis. In most cases, sonograms reflected severe inflammation, with multiple sonographic signs.

CONCLUSIONS

Although multiple sonographic signs are associated with complicated cholecystitis, none of them is sensitive and specific enough to definitively diagnose it. Sonograms usually reflect severe inflammation, with numerous sonographic signs. Thus, in the right clinical context, sonograms of severe cholecystitis should alert radiologists to the possibility of complications.

Usefulness of contrast-enhanced US in the diagnosis of acute gangrenous cholecystitis: A comparative study with surgical and pathological findings

OBJECTIVE

To prospectively determine the usefulness of contrast-enhanced ultrasound (CEUS) in the diagnostic assessment of acute gangrenous cholecystitis, using histopathology as the reference method.

MATERIAL & METHODS

The local institutional review board approved the study protocol, and all patients at enrollment provided a written informed consent. From December 2011 to July 2014, all patients with a clinical-sonographic diagnosis of acute cholecystitis underwent a CEUS examination. We included only patients who underwent cholecystectomies within 24-h of CEUS. Radiologists in the course of routine clinical care interpreted the US and CEUS images at the end of the examination, filling out a questionnaire. Two radiologists, blinded to the final diagnosis, independently reviewed the video CEUS sequences for the presence of defects of the gallbladder wall enhancement. Associations between the sonographic findings and histological gangrenous cholecystitis were evaluated by using univariate and multivariate logistic regression analysis.

RESULTS

A total of 150 patients were analyzed. The histological diagnoses were 41 (27%) nongangrenous cholecystitis and 109 acute gangrenous cholecystitis (73%). Multivariate analysis of the predictive parameters at univariate analysis revealed that only leukocytosis, diabetes mellitus, lithiasis and defects of wall enhancement on CEUS were independent variables related to gangrenous cholecystitis. The presence of enhancement defects on CEUS enabled the diagnosis of the gangrenous form with sensitivity between 85 and 91% and specificity of 67.5-84.8%. Interobserver agreement for CEUS interpretation was good (median k value: 0.664; range, 0.655-0.680).

CONCLUSION

Local or widespread absence of gallbladder wall enhancement on CEUS is associated with the presence of gangrenous acute cholecystitis.

Can endoscopic ultrasound-guided fine needle aspiration offer clinical benefit for thick-walled gallbladders?

BACKGROUND

No previous studies have compared cytology obtained under endoscopic transpapillary gallbladder drainage (ETGD) and EUS-guided fine needle aspiration (EUS-FNA) for thick-walled gallbladders.

AIM

The present study investigated the diagnostic yield of bile cytology under ETGD and EUS-FNA for gallbladder tumors.

METHODS

A total of 69 patients were diagnosed as having gallbladder wall thickening. Among these patients, 28 patients were diagnosed by clinical follow-up, solely by imaging such as computed tomography or by histological examination of surgical specimens. The remaining 41 patients underwent ETGD and/or EUS-FNA. In these 41 patients, the clinical data collected included gender, age, diameter of gallbladder wall, site of gallbladder wall thickening, final diagnosis, adverse events, and diagnostic yield of ETGD and EUS-FNA.

RESULTS

Cyto-histological diagnosis with EUS-FNA was higher than that with ETGD, with a sensitivity of 100 versus 71%, specificity of 100 versus 94%, and accuracy of 100 versus 88%, respectively, in the two groups. In addition, the sampling adequacy of EUS-FNA was 100%. Adverse events were seen in five patients in the ETGD group (mild pancreatitis), although no adverse events were seen in the EUS-FNA group (P = 0.08).

CONCLUSION

Our results suggest that EUS-FNA can be safely performed for the diagnosis of gallbladder lesions. Further, this procedure may be the diagnostic method of choice over cytology of bile juice obtained via ETGD to obtain histological evidence of gallbladder cancer.

Nuclear medicine tests for acute gastrointestinal conditions

Acute cholecystitis (AC) and lower-gastrointestinal (GI) bleeding are 2 emergencies commonly encountered in nuclear medicine. Evidence of AC on hepatobiliary scintigraphy (HBS) allows for confident diagnosis and provides support for definitive surgical treatment. Proper patient preparation is essential for HBS including fasting and the use of pharmacologic adjuncts is sometimes required. Pharmacologic adjuncts may also be administered during HBS to shorten the length of the examination and increase its specificity. In the interpretation of HBS, there are several sources of false-positive results to be aware of, most commonly chronic cholecystitis. False-negative results on HBS are usually the result of mistaking another structure, such as a dilated cystic duct, for the gallbladder. Abdominal ultrasound is the appropriate initial test in patients with suspected AC, but HBS is an excellent second tier test for the diagnosis of AC in the work-up of indeterminate cases by sonography. GI bleeding scintigraphy plays an important role in the evaluation and management of patients with acute lower-GI bleeding. Scintigraphy serves to localize sites of active GI bleeding and stratify those patients who would benefit from aggressive treatment (surgery or arteriography) vs those who can be managed medically. Pretest involvement of respective services is critical for successful bleeding site confirmation and therapy by interventional radiology or surgery or both. Single photon emission computed tomography/computed tomography erythrocyte scintigraphy has demonstrated superior accuracy and precision over planar scintigraphy in the diagnosis of acute GI bleeding. Additionally, single photon emission computed tomography/computed tomography scintigraphy of GI bleeding provides useful supplemental anatomical information that benefits patient management.

Acute cholecystitis: do sonographic findings and WBC count predict gangrenous changes?

OBJECTIVE

The purpose of our study was to determine, first, if gallbladder wall striations in patients with sonographic findings suspicious for acute cholecystitis are associated with gangrenous changes and certain histologic features; and, second, if WBC count or other sonographic findings are associated with gangrenous cholecystitis.

MATERIALS AND METHODS

Sixty-eight patients who underwent cholecystectomies within 48 hours of sonography comprised the study group. Sonograms and reports were reviewed for wall thickness, striations, Murphy sign, pericholecystic fluid, wall irregularity, intraluminal membranes, and luminal short-axis diameter. Medical records were reviewed for WBC count and pathology reports for the diagnosis. Histologic specimens were reviewed for pathologic changes. Statistical analyses tested for associations between nongangrenous and gangrenous cholecystitis and sonographic findings and for associations between wall striations and histologic features.

RESULTS

Ten patients had gangrenous cholecystitis and 57, nongangrenous cholecystitis. One had cholesterolosis. Thirty patients had wall striations: 60% had gangrenous and 42% nongangrenous cholecystitis. There was no association with the pathology diagnosis (p = 0.32). There was no association between any histologic feature and wall striations (p ≥ 0.19). A Murphy sign was reported in 70% of patients with gangrenous cholecystitis and in 82% with nongangrenous cholecystitis; there was no association with the pathology diagnosis (p = 0.39). Wall thickness and WBC count were greater in patients with gangrenous cholecystitis than in those with nongangrenous cholecystitis (p ≤ 0.04).

CONCLUSION

Gallbladder wall thickening and increased WBC counts were associated with gangrenous cholecystitis; however, there was considerable overlap between the two groups. Wall striations and a negative Murphy sign were not associated with gangrenous cholecystitis.

TG13 diagnostic criteria and severity grading of acute cholecystitis (with videos)

Since its publication in 2007, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) have been widely adopted. The validation of TG07 conducted in terms of clinical practice has shown that the diagnostic criteria for acute cholecystitis are highly reliable but that the definition of definite diagnosis is ambiguous. Discussion by the Tokyo Guidelines Revision Committee concluded that acute cholecystitis should be suspected when Murphy's sign, local inflammatory findings in the gallbladder such as right upper quadrant abdominal pain and tenderness, and fever and systemic inflammatory reaction findings detected by blood tests are present but that definite diagnosis of acute cholecystitis can be made only on the basis of the imaging of ultrasonography, computed tomography or scintigraphy (HIDA scan). These proposed diagnostic criteria provided better specificity and accuracy rates than the TG07 diagnostic criteria. As for the severity assessment criteria in TG07, there is evidence that TG07 resulted in clarification of the concept of severe acute cholecystitis. Furthermore, there is evidence that severity assessment in TG07 has led to a reduction in the mean duration of hospital stay. As for the factors used to establish a moderate grade of acute cholecystitis, such as leukocytosis, ALP, old age, diabetes, being male, and delay in admission, no new strong evidence has been detected indicating that a change in the criteria used in TG07 is needed. Therefore, it was judged that the severity assessment criteria of TG07 could be applied in the updated Tokyo Guidelines (TG13) with minor changes. TG13 presents new standards for the diagnosis, severity grading and management of acute cholecystitis. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

Hepatobiliary scintigraphy in acute cholecystitis

Hepatobiliary scintigraphy is a mature imaging technique for evaluation of patients with acute cholecystitis (AC). It is effective in calculous and acalculous forms of AC. The test is used in contemporary medical practice as the arbiter when the findings from screening abdominal ultrasound do not fit a clinical picture. It is also performed in severely ill patients who have AC suspected on other testing, but whose frail condition and high operative risk demand the highest level of certainty. This review, therefore, examines all technique variations of hepatobiliary scintigraphy, offering an approach that may best fit a variety of clinical situations and philosophies on AC.

Sonography of gangrenous cholecystitis

Gangrenous cholecystitis is an acute surgical emergency, which requires early cholecystectomy. Differentiation of patients with gangrenous cholecystitis from those with non-gangrenous cholecystitis can be difficult, both clinically and with imaging. Careful attention to the following sonographic signs suggests the presence of gangrenous cholecystitis decreased focal wall perfusion on Color Doppler, irregular gall bladder mucosal outline, gall bladder wall thickening with signs of de-lamination, gas within the gall bladder, absence of calculi, and large peri-cholecystic collections. Both sonogram with color flow imaging and contrast-enhanced Computed tomography are complementary investigations to establish this important diagnosis in critically ill patients.

Complicated cholecystitis: the complementary roles of sonography and computed tomography

Acute cholecystitis is a common cause of abdominal pain in the Western world. Unless treated promptly, patients with acute cholecystitis may develop complications such as gangrenous, perforated, or emphysematous cholecystitis. Because of the increased morbidity and mortality of complicated cholecystitis, early diagnosis and treatment are essential for optimal patient care. Nevertheless, complicated cholecystitis may pose significant challenges with cross-sectional imaging, including sonography and computed tomography (CT). Interpreting radiologists should be familiar with the spectrum of sonographic findings seen with complicated cholecystitis and as well as understand the complementary role of CT. Worrisome imaging findings for complicated cholecystitis include intraluminal findings (sloughed mucosa, hemorrhage, abnormal gas), gallbladder wall abnormalities (striations, asymmetric wall thickening, abnormal gas, loss of sonoreflectivity and contrast enhancement), and pericholecystic changes (echogenic fat, pericholecystic fluid, abscess formation). Finally, diagnosis of complicated cholecystitis by sonography and CT can guide alternative treatments including minimally invasive percutaneous and endoscopic options.

Gallbladder imaging

The treatment of gallbladder disease has been revolutionized by improvements in laparoscopic surgery as well as endoscopic and radiologic interventional techniques. Therapeutic success is dependent on accurate radiologic assessment of gallbladder pathology. This article describes recent technical advances in ultrasonography, multidetector computed tomography, magnetic resonance imaging, positron emission tomography, and scintigraphy, which have significantly improved the accuracy of noninvasive imaging of benign and malignant gallbladder disease. The imaging findings of common gallbladder disorders are presented, and the role of each of the imaging modalities is placed in perspective for optimizing patient management.

Cross-sectional imaging of acute and chronic gallbladder inflammatory disease

OBJECTIVE

The purpose of this article is to provide a comprehensive review of the clinical and cross-sectional imaging features of a variety of acute and chronic gallbladder inflammatory diseases.

CONCLUSION

Inflammatory gallbladder diseases are a common source of abdominal pain and cause considerable morbidity and mortality. Although acute uncomplicated cholecystitis and chronic cholecystitis are frequently encountered, numerous other gallbladder inflammatory conditions may also occur that can be readily diagnosed by cross-sectional imaging.

MR imaging of acute biliary disorders

In patients with acute right-sided epigastric pain, jaundice, and a high fever, it is essential to accurately diagnose the cause of the symptoms, differentiate acute biliary disorders from nonbiliary disorders, and evaluate the severity of the disease. Gray-scale ultrasonography (US) and computed tomography (CT) are useful primary imaging modalities, but their results are not always conclusive. Magnetic resonance (MR) imaging, including MR cholangiopancreatography, can be a valuable complement to US and CT when additional information is needed. MR images have excellent tissue contrast and can provide more specific information, allowing diagnosis of complications that arise from acute cholecystitis, such as empyema, gangrenous cholecystitis, gallbladder perforation, enterocholecystic fistula, emphysematous cholecystitis, and hemorrhagic cholecystitis. In addition, causes of obstructive jaundice, acute suppurative cholangitis, and hemobilia can be clearly demonstrated with multisequence MR imaging. Single-section MR cholangiopancreatography and heavily T2-weighted imaging, in combination with fat-suppressed T1- and T2-weighted imaging, provide comprehensive and detailed information about the biliary system around the obstruction site, biliary calculi, inflammatory processes, purulent material, abscesses, gas, and hemorrhage. Contrast-enhanced MR imaging is useful for evaluation of the gallbladder wall; lack of enhancement and disruption of the wall may be findings specific for gangrenous cholecystitis and gallbladder perforation, respectively.

Imagerie des épaississements de la paroi vésiculaire

Thickening of the gallbladder wall may result from a large spectrum of pathological conditions, intrinsic as well as extrinsic to the biliary tract, and may have different appearances. Accurate diagnosis is usually established after a correlation of imaging findings, laboratory data and clinical history. US remains the initial imaging modality for the evaluation of acute right upper quadrant pain. CT and MRI are complementary to US and have an increasing role in assessing a thickened-wall gallbladder.

From the RSNA refresher courses: imaging evaluation for acute pain in the right upper quadrant

Acute cholecystitis is the most common cause of acute pain in the right upper quadrant (RUQ), and urgent surgical removal of the gallbladder is the treatment of choice for uncomplicated disease. However, cross-sectional imaging is essential because more than one-third of patients with acute RUQ pain do not have acute cholecystitis. In addition, patients with complications of acute cholecystitis, such as perforation, are often best treated with supportive measures initially and elective cholecystectomy at a later date. Ultrasound (US) is the primary imaging modality for assessment of acute RUQ pain; US is both sensitive and specific in demonstrating gallstones, biliary dilatation, and features that suggest acute inflammatory disease. Occasionally, additional imaging modalities are indicated. Computed tomography is valuable, especially for confirming the extent and nature of the complications of acute cholecystitis. Magnetic resonance cholangiopancreatography is helpful in complicated ductal disease (eg, recurrent pyogenic cholangiohepatitis) when more detailed diagnostic information is required for treatment planning, whereas endoscopic retrograde cholangiopancreatography is used when biliary intervention is required (eg, treatment of choledocholithiasis). Successful imaging with all modalities requires familiarity with both the characteristic and the unusual features of a wide variety of pathologic conditions. In addition, potential pitfalls must be recognized and avoided.

Use of a predictive equation for diagnosis of acute gangrenous cholecystitis

BACKGROUND

Factors previously identified by multivariate logistic regression that were predictive for gangrenous cholecystitis (GC) were used to develop a predictive equation. Our objective was to evaluate the sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values of this equation for detecting GC in patients with acute cholecystitis (AC).

METHODS

Medical records of patients who presented to a tertiary care hospital with AC were reviewed. Twenty-one patient and clinical variables were recorded. We prospectively tested the results of the following equation against pathologic diagnosis: P=e((0.7116+0.9944.DM+1.7157.WBC-1.0319.ALT.2.0518.ALP+2.7078.PCF))/(1+e([-0.7116+0.9944.DM+1.7157.WBC-1.0319.ALT-2.0518.ALP+2.7078.PCF])), where P = predicted value; DM = diabetes mellitus; WBC = white blood cell count; ALT = alanine aminotransferase; AST = aspartate aminotransferase; and PCF = pericholecystic fluid.

RESULTS

Ninety-eight patients presented with AC and 18% had GC (18 of 98). Using a cutoff of P = 0.724, our equation had a specificity of 93%, sensitivity of 83%, PPV of 71%, and NPV of 96%, P <0.001 for the detection of GC.

CONCLUSIONS

Our study demonstrates the equation may be useful in detecting the subset of AC patients who have GC.

Can gangrenous cholecystitis be prevented?: a plea against a "wait and see" attitude

BACKGROUND/AIMS

A delay in recognizing and treating an inflamed gallbladder may increase the risk of a necrotic evolution and represent a critical factor affecting the progression of the inflammatory process. Aim of the study is to assess the therapeutic attitude in patients with histologically proved gangrenous cholecystitis, to find out whether it could play a role in the progression of the inflammatory condition.

METHODOLOGY

Twenty-seven patients with gangrenous cholecystitis at histology were compared with a matched-control group with phlegmonous cholecystitis.

RESULTS

Age, gender, ASA score, and concomitant diseases did not differ significantly in both groups. WBC was significantly higher (P = 0.026) in patients with gangrene. Ultrasounds were unhelpful in identifying the severity of the disease. Patients with gangrenous gallbladder showed a significantly increased (P = 0.0006) admission delay compared with controls (104.3+/-15.3 hours vs. 59.7+/-7.7 hours). Surgeon's delay, morbidity and mortality were not different in both groups.

CONCLUSION

Patient's delay before hospitalization may represent a crucial factor in the progression toward a more severe disease in acute cholecystitis. The time between symptoms onset and hospital admission (and consequently surgery) was significantly longer in patients with gangrenous cholecystitis, further emphasizing the need for an early (if not urgent) surgical treatment in acute cholecystitis, even with mild symptoms.

Prognostic factors for the development of gangrenous cholecystitis

BACKGROUND

The operative morbidity and mortality for patients with gangrenous cholecystitis (GC) remains high. Our objective was to identify preoperative prognostic factors for GC in order to distinguish this subset of patients with acute cholecystitis (AC).

METHODS

From 1/98 to 11/01 the medical records of patients who presented with the diagnosis of AC were reviewed. Univariate and multivariate analysis were performed on this retrospective data.

RESULTS

Of 113 patients with acute cholecystitis, 45 (39.8%) had histologically confirmed gangrenous cholecystitis. Nine variables were identified that were associated with GC by univariate analysis: age > or =51 years, African-American race, white blood cell count > or =15,000, diabetes, pericholecystic fluid, asparate aminotransferase, alanine aminotransferase, alkaline phosphatase, and lipase. Two variables were identified by multivariate analysis: diabetes, and white blood cell count.

CONCLUSIONS

Our data suggest that patients with a history of diabetes and white blood cell count >15,000 to be at an increased risk for having GC upon presentation and they should have urgent surgical intervention.

Ultrasound and CT evaluation of emergent gallbladder pathology

Ultrasound is the initial imaging modality of choice for the evaluation of suspected acute gallbladder disorders, and is often sufficient for correct diagnosis. CT also plays a vital role, however, in the evaluation of acute gallbladder pathology. CT is particularly useful in situations where ultrasound findings are equivocal. CT is also extremely valuable in the assessment of suspected complications of acute cholecystitis, particularly emphysematous cholecystitis, hemorrhagic cholecystitis, and gallbladder perforation, which are often very difficult diagnoses to establish at sonography. If CT is the initial imaging test performed in a patient with abdominal pain of uncertain etiology, recognition of the various disorders described in this article may eliminate the need for further imaging and facilitate appropriate management.

The interrupted rim sign in acute cholecystitis: a method to identify the gangrenous form with MRI

We present the imaging findings on MR of a patient with acute gangrenous cholecystitis that demonstrated patchy enhancement of the gallbladder mucosa on gadolinium-enhanced fat-saturated T1-weighted gradient echo images. This interrupted rim of mucosal enhancement correlated with patchy areas of necrosis and inflammation of the gallbladder mucosa on the histopathological examination.

False negative biliary scintigraphy in gangrenous cholecystitis

Gangrenous cholecystitis is a serious complication of acute cholecystitis and is associated with increased morbidity and mortality rates. We report a case in which the diagnosis was suggested by ultrasound, but cholecystectomy delayed due to atypical clinical presentation and a false negative radionuclide biliary scan.

CT findings in acute gangrenous cholecystitis

OBJECTIVE

The purpose of this study was to determine the CT findings in acute gangrenous cholecystitis.

MATERIALS AND METHODS

Four observers retrospectively reviewed CT scans in 75 patients (23 with acute gangrenous cholecystitis, 25 with acute non-gangrenous cholecystitis, and 27 without cholecystitis). The following findings were evaluated: distention, mural thickening, wall enhancement, irregular wall, wall striation, intraluminal membranes, pericholecystic inflammation, gallstones, pericholecystic fluid, enhancement of liver parenchyma, pericholecystic abscess, and gas in the wall or lumen. Sensitivity and specificity of CT for gangrenous cholecystitis and for each finding were calculated. Two reviewers in consensus measured gallbladder dimension and wall thickness. Logistic regression models were used to predict gangrenous versus non-gangrenous cholecystitis.

RESULTS

Sensitivity, specificity, and accuracy of CT for acute cholecystitis were 91.7%, 99.1%, and 94.3%, respectively, and for acute gangrenous cholecystitis were 29.3%, 96.0%, and 64.1%, respectively. Findings with the highest specificity for gangrenous cholecystitis were gas in the wall or lumen (100%), intraluminal membranes (99.5%), irregular or absent wall (97.6%), and abscess (96.6%). The difference between the mean gallbladder wall thickness and the short-axis dimension for the two groups with cholecystitis was statistically significant. In three patients with gangrenous cholecystitis, no mural enhancement was seen. Pericholecystic fluid also achieved statistical significance for the diagnosis of gangrene. Multivariate logistic regression analysis showed that the overall accuracy of CT for gangrenous cholecystitis was 86.7%.

CONCLUSION

CT findings most specific for acute gangrenous cholecystitis are gas in the wall or lumen, intraluminal membranes, irregular wall, and pericholecystic abscess. Gangrenous cholecystitis is associated with a lack of mural enhancement, pericholecystic fluid, and a greater degree of gallbladder distention and wall thickening.

Gallbladder carcinoma: radiologic-pathologic correlation

Primary carcinoma of the gallbladder is an uncommon, aggressive malignancy that affects women more frequently than men. Older age groups are most often affected, and coexisting gallstones are present in the vast majority of cases. The symptoms at presentation are vague and are most often related to adjacent organ invasion. Therefore, despite advances in cross-sectional imaging, early-stage tumors are not often encountered. Imaging studies may reveal a mass replacing the normal gallbladder, diffuse or focal thickening of the gallbladder wall, or a polypoid mass within the gallbladder lumen. Adjacent organ invasion, most commonly involving the liver, is typically present at diagnosis, as is biliary obstruction. Periportal and peripancreatic lymphadenopathy, hematogenous metastases, and peritoneal metastases may also be seen. The vast majority of gallbladder carcinomas are adenocarcinomas. Because most patients present with advanced disease, the prognosis is poor, with a reported 5-year survival rate of less than 5% in most large series. The radiologic differential diagnosis includes the more frequently encountered inflammatory conditions of the gallbladder, xanthogranulomatous cholecystitis, adenomyomatosis, other hepatobiliary malignancies, and metastatic disease.

Role of laparoscopic cholecystectomy in the management of gangrenous cholecystitis

BACKGROUND

Laparoscopic cholecystectomy is increasingly being employed as the initial surgical approach in patients with acute cholecystitis. Gangrenous cholecystitis will be unexpectedly encountered in a proportion of these patients. The applicability of laparoscopic techniques and its outcome in this group of patients remain poorly defined. This paper presents our experience with laparoscopic cholecystectomy in the treatment of patients with gangrenous cholecystitis.

METHODS

From January 1994 to March 1999, 281 patients underwent laparoscopic cholecystectomy for acute cholecystitis. Operative and histopathologic data were obtained and the subgroup with gangrenous cholecystitis identified (53 of 281, 18.8%). Laparoscopic cholecystectomy was the initial surgical approach in 44 (83%) and was successfully completed in 30 of 44 (68%) patients. Conversion to an open cholecystectomy became necessary in 14 of 44 (32%). A retrospective review comparing these two groups of patients was performed.

RESULTS

Of the 44 patients, there were 25 males and 19 females, with a mean age of 64.6 years. Mean duration of symptoms prior to presentation was 2.3 and 2.9 days in the laparoscopic and conversion groups, respectively. Clinical presentation included the presence of right upper quadrant pain (98%), leukocytosis (91%), fever (16.3%), and jaundice (9%). Liver function test abnormalities included elevations of alkaline phosphatase (25%), aspartate aminotransferase (20.4%), alanine aminotransferase (22.7%), and total bilirubin (18.1%). Ultrasonography revealed the presence of gallstones (88.6%), gallbladder wall thickening (52.3%), and pericholecystic fluid (20.5%). Air in the gallbladder wall and intraluminal membranes were present in 2 patients and 1 patient, respectively. Nuclear scans performed in 29 patients revealed cystic duct obstruction in all 29. The rim sign was present in 1 patient. A laparoscopic cholecystectomy was attempted in 44 of 53 patients and was successfully completed in 30 (68%). Conversion to an open procedure became necessary in 14 of 44 (32%). No difference in preoperative factors was noted among the two groups. The mean duration of surgery in patients undergoing a successful laparoscopic cholecystectomy was 107 minutes versus 110 minutes when conversion was necessary. There were no deaths in the study population. Morbidity occurred in 40% of the laparoscopic group and 71% of the conversion group. No patient in the laparoscopic group required admission to the intensive care unit. In contrast, 4 of 14 patients in the conversion group required a mean of 2.6 days in the intensive care unit. Postoperative hospital stay was 3.3 versus 5.5 days in the two groups, respectively.

CONCLUSIONS

Preoperative factors did not predict conversion in patients undergoing laparoscopic cholecystectomy for presumed acute cholecystitis who are found to have gangrenous cholecystitis. Duration of surgery is not significantly prolonged and outcome in terms of morbidity, admission to the intensive care unit, and hospital stay are significantly better in patients in whom laparoscopic cholecystectomy is successful.

Sonography for selecting candidates for laparoscopic cholecystectomy: a prospective study

OBJECTIVE

We assessed the value of sonography in predicting intraoperative difficulties for patients undergoing laparoscopic cholecystectomy and in identifying indicators for conversion to conventional cholecystectomy.

SUBJECTS AND METHODS

Upper abdominal sonography was performed (according to a checklist) in 75 consecutive patients before laparoscopic cholecystectomy. Sonographic findings were verified by the surgeon in the operating room.

RESULTS

Conversion from laparoscopic surgery to laparotomy was performed in five patients (6.7%). Of 75 patients, 19 had sonograms revealing gallbladder wall thickening (>4 mm); surgical preparation difficulties in 16 of these patients led to laparotomy in four patients. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of technical difficulties were 66.7%, 94.1%, 84.2%, and 85.3%, respectively. Sensitivity, specificity, positive predictive value, and accuracy of wall thickening as an indicator of surgical conversion were 80.0%, 78.6%, 21.1%, and 78.7%, respectively. Technical difficulties at laparoscopy occurred in all five patients with pericholecystic fluid on sonography (sensitivity, 20.8%; specificity, 100%; positive predictive value, 100%; accuracy, 74.7%) and led to laparotomy in three patients (sensitivity 60.0%, specificity 97.1%, positive predictive value 60%, accuracy 94.7%). The accuracy of sonography for cholecystolithiasis was 100%.

CONCLUSION

On sonography, gallbladder wall thickening is the most sensitive indicator and pericholecystic fluid is the most specific indicator of technical difficulties during laparoscopic cholecystectomy. Such difficulties may require conversion to laparotomy.

Sonographic Diagnosis of Gangrenous Cholecystitis

Gangrenous cholecystitis is an advanced form of acute cholecystitis that is associated with an increased complication rate. Although somewhat controversial, common belief is that patients with nongangrenous acute cholecystitis can be treated medically followed by elective surgery. However, all agree, patients with gangrenous cholecystitis should undergo emergent cholecystectomy. Ultrasound can play an important role in this situation, by helping to differentiate those patients who require emergent surgical therapy from those who do not.

Imaging and intervention in patients with acute right upper quadrant disease

Because of the high diagnostic yield, its widespread availability and the possibility of bedside examinations, US has become the imaging modality of choice in patients with acute right upper quadrant pain caused by inflammatory disorders such as liver abscesses, acute cholangitis and acute cholecystitis. Computed tomography (CT) can be reserved for more complex cases. US, often in combination with fluoroscopy, is also widely used to control interventions. In patients with liver abscesses the therapeutic strategy is determined by the size of the abscess, its uni- or multifocal presentation and the causative micro-organisms cultured after diagnostic percutaneous aspiration. Small-sized pyogenic abscesses (< 3 cm), most fungal and amoebic abscesses can be treated medically. Large-sized pyogenic abscesses should be drained percutaneously and can be cured in 75-90%. Surgery should be restricted to patients with prolonged sepsis after percutaneous drainage and patients with infected pre-existing hepatic lesions. In patients with acute cholangitis drainage of the infected bile is essential. Invasive imaging such as percutaneous or endoscopic cholangiography procedures such as nasobiliary drainage, stent placement and sphincterotomy has decreased mortality rates dramatically. Percutaneous drainage should be considered in patients in whom endoscopic procedures fail. Surgery may have a place in the treatment of bile duct obstruction which causes cholangitis. In patients with suspected acute cholecystitis, imaging modalities such as cholescintigraphy and CT can be reserved for patients with inconclusive sonographic studies and more complex cases. The contribution of percutaneous gallbladder aspiration and culture to diagnose acute cholecystitis seems limited. Percutaneous cholecystostomy is an effective procedure with a low morbidity and mortality for high-risk patients. The drainage catheter in the gallbladder does not interfere with cholecystectomy at a later stage in patients with calculous cholecystitis. In most patients with acalculous cholecystitis, percutaneous cholecystectomy provides a definitive treatment.

Loss of the mucosal lining/gall-bladder wall echo: a sonographic sign of gangrenous cholecystitis

An additional sonographic sign of gangrenous cholecystitis, namely the loss of the mucosal/gall-bladder wall echo in a setting of acute cholecystitis, is described. It was found prospectively in six patients and correlated well with the presence of mucosal/wall necrosis on histological gallbladder specimens. Other reported signs of gangrenous cholecystitis are reviewed.