Medical Image of the Month: Perforated Gangrenous Cholecystitis

Figure 1. A sagittal CT of the abdomen and pelvis without intravenous contrast demonstrates a low-density stone in the neck of the gallbladder (red arrow) along with large amount of complex fluid adjacent to the gallbladder (outlined in green) consistent with a large pericholecystic abscess. A large amount of fat-stranding in the adjacent mesenteric fat is also noted (blue arrow).

Clinical Scenario: A 47-year-old lady with a past medical history of hypertension, DVT on Xarelto, and methamphetamine use presented with a 3-day history of progressive right upper quadrant pain. Physical examination demonstrated marked right upper quadrant tenderness with palpation and significant rebound tenderness. A CT of the abdomen and pelvis without intravenous contrast demonstrated findings consistent with acute calculus cholecystitis with evidence of perforation and a pericholecystic abscess. The patient was taken emergently to the operating room where she underwent an open cholecystectomy which demonstrated perforated gangrenous cholecystitis with a large abscess in the gallbladder fossa. She was admitted to the ICU post-operatively due septic shock and did well with fluid resuscitation and antibiotic administration.

Discussion: Acute cholecystitis is the most common acute complication of cholelithiasis and accounts for 3-9% of hospital admissions for acute abdominal pain. Eight to 95% of cases of acute cholecystitis are the result of a stone obstructing the cystic duct or gallbladder neck. Acute acalculous cholecystitis accounts for the remaining 5-20% of cases of cholecystitis. Ultrasound is the preferred initial examination for patients suspected of having cholecystitis. Gangrenous cholecystitis is the most common complication of acute cholecystitis and often necessitates emergent surgery. Perforated cholecystitis is most commonly seen in association with gangrenous cholecystitis. Perforation most commonly occurs at the gallbladder fundus where blood flow to the gallbladder is most distal.

Lauren Blackley, AG-ACNP-S¹

Madhav Chopra MD²

Tammer El-Aini MD²

¹Grand Canyon University- College of Nursing

²Banner University Medical Center – Main Campus, Department of Pulmonary and Critical Care

Reference

1. Ratanaprasatporn L, Uyeda JW, Wortman JR, Richardson I, Sodickson AD. Multimodality Imaging, including Dual-Energy CT, in the Evaluation of Gallbladder Disease. Radiographics. 2018 Jan-Feb;38(1):75-89. [CrossRef] [PubMed]

Cite as: Blackley L, Chopra M, El-Aini T. Medical Image of the Month: Perforated Gangrenous Cholecystitis. Southwest Journal of Pulmonary and Critical Care. 2021;22(5):100-1. doi: https://doi.org/10.13175/swjpcc010-21 PDF 

May 2021 Imaging Case of the Month: A Growing Indeterminate Solitary Nodule

Joseph Jeehoon Kim, MD^°

Kenneth K. Sakata, MD^‡

Natalya Azadeh, MD, MPH^‡

Maxwell Smith, MD^↑

Michael B. Gotway, MD^†

^°Department of Medicine, Mayo Clinic Arizona

^↑Department of Laboratory Medicine and Pathology, Mayo Clinic Arizona

^‡Division of Pulmonary and Critical Care Medicine, Mayo Clinic Arizona

^†Department of Radiology, Mayo Clinic, Arizona

5777 East Mayo Boulevard

Phoenix, Arizona 85054

A 58-year-old woman with a history of orthotopic heart transplant, performed for Adriamycin-induced cardiomyopathy, treated with mycophenolate and tacrolimus, presented for routine interval follow up. The patient’s past medical history was significant for follicular thyroid carcinoma treated with total thyroidectomy and bilateral breast carcinoma in remission as well as hypothyroidism and type II diabetes mellitus. In addition to tacrolimus and mycophenolate, the patient’s medications included aspirin, insulin, itraconazole (for anti-fungal prophylaxis), levothyroxine, prednisone (tapering since transplant), and valganciclovir. The patient recently complained of rhinorrhea and cough productive of brown-tinged sputum, improving over the previous 2 weeks; she denied fever, chills, shortness of breath, night sweats chest pain, or gastrointestinal symptoms.

Physical examination showed the patient to be afebrile with normal heart and respiratory rates and blood pressure. Her room air oxygen saturation was 99%.

The patient’s complete blood count and serum chemistries showed largely normal values, with the white blood cell count at the upper normal at 9.7 x 10⁹ /L (normal, 4-10 x 10⁹ /L). Her liver function testing and renal function testing parameters were also within normal limits. Echocardiography showed normal left ventricular systolic function. The patient underwent frontal chest radiography (Figure 1).

Figure 1. Frontal chest radiography.

Which of the following represents an appropriate interpretation of her frontal chest radiograph? (Click on the correct answer to be directed to the second of nine pages). 

1. Frontal chest radiography shows a right pleural effusion
2. Frontal chest radiograph shows a left apical nodule
3. Frontal chest radiography shows multifocal consolidation
4. Frontal chest radiography shows peribronchial and mediastinal lymphadenopathy
5. Frontal chest radiography shows cardiomegaly

Cite as: Kim JHJ, Sakata KK, Azadeh N, Smith M, Gotway MB. May 2021 Imaging Case of the Month: A Growing Indeterminate Solitary Nodule. Southwest J Pulm Crit Care Med. 2021;229(5):88-99. doi: https://doi.org/10.13175/swjpcc013-21 PDF