acute cholecystitis

Acute cholecystitis

Dr/ Hytham Nafady

Etiology

U/S• Stones (echogenic with back shadow).• Stone impacted in cystic duct.• Sludge.• Gall bladder distension• Mural thickening > 3 mm.• Mural haziness (poor definition).• Mural striations (3 layered appearance with

sonolucent middle layer due to edema).• Peri-cholecystic fluid collection.• Sonographic Murphy’s sign.

Stones

Stone at fundus

Obstructing stone at gall bladder neck

Sludge

Mural thickening

Duplex Hypervascularity of the gall bladder wall

CT

1. Stones.2. Gallbladder distension (> 5 cm in transverse

diameter).3. Mural thickening.4. Mural hyper-enhancement.5. Peri-cholecystic fluid collection.6. Peri-cholecystic inflammatory fat stranding.7. Enhancement of the adjacent liver

parenchyma due to reactive hyperaemia.

Reactive hyperemia of the adjacent liver parenchyma

MRCP

• Impacted stone at the gall bladder neck or cystic duct.

• The stone appears as a filling defect of signal void withing the high signal intensity bile.

HIDA scan

• Non visualized gall bladder after 60 minutes.

Causes of false positive HIDA scan:Total parentral nutrition (fasting).Sphincerotomy.Sever liver disease.

Dilated cardiomyopathy with hepatic congestion & gall bladder wall thickening

Gall bladder mural thickening in a patient with pancreatitis

Complication Definition Signs

Emphysematous cholecystitis

Acute cholecystitis, with secondary infection of the gall bladder wall.

Intramural or intraluminal air.

Hemorrhagic cholecystitis

Acute cholecystitis, with intraluminal hemorrhage.

Intraluminal hemorrhage.

Gangrenous cholecystitis

Acute cholecystitis, with ishemia & necrosis of the gall bladder wall.

Mucosal defects.Sloughed membrane.

Gall bladder perforation

Acute. Acute peritonitis.

Subacute. Pericholecystic abscess.

Chronic. Internal biliary fistula.

Vascular complications

Cystic artery pseudo-aneurysm.Portal vein thrombosis.

Gangrenous cholecystitis

Sloughed membrane

Sludge

stone

Hemorrhagic cholecystitis

Hemorrhagic cholecystitis

Emphysematous cholecystitis

U/S• Sagittal sonogram shows a curvilinear

echogenic interface in the gallbladder fossa with reverberation artifact 

Supine view

Upright view CT

Gall bladder perforation

Subacute perforation(contained peforation)

Pericholecystic abscess

defect

Subacute perforation(contained peforation)

Pericholecystic abscess

defect

Cholecysto-enteric fistula

BL = dilated loops of proximal small intestine

Gall stone ileus

Cholecystoenteric fistula & gall stone ileus

Cholecysto-duodenal fistula

Bouveret syndromeduodenal obstruction by a gall stone

Cystic artery pseudo-aneurysm

Portal vein thrombosis

DD of Rt upper quadrant pain

• Acute cholecystitis.

• Acute pancreatitis.

• Hepatitis.

• Acute right pyelonephritis.

• Perforated duoedenal ulcer.