Cholecystic Cholecystic Disease - Lieberman's eRadiologyeradiology.bidmc.harvard.edu/LearningLab/gastro/Sahagun.pdf · Cholecystic Cholecystic Disease ... Murphy’s sign. z ... A

CholecysticCholecystic DiseaseDisease

Omar S. Sahagun, Harvard Medical School, Year IVGillian Lieberman, MD

Omar S. Sahagun

Gillian Lieberman, M.D.

FactsFacts10–15% of U.S. adults have gallstones necessitating more than 600K annual cholecystectomies

Biliary disease is a major consideration in a patient with acute abdominal pain

Clinical differentiation of RUQ tenderness due to hepatobiliary disease versus multiple other causes, is extremely difficult

Imaging therefore plays a key role in the evaluation of acute RUQ pain

Omar S. Sahagun


Risk FactorsRisk Factors

The 6 “F’s”:1. Fat2. Female3. Forty4. Fertile5. Fatty food intolerance6. Flatulance

Omar S. Sahagun


Classic Signs & SymptomsClassic Signs & Symptoms1. RUQ or epigastric pain2. N/V

3. Anorexia

4. Fatty food ingestion ≈

1 hour before the onset of pain

5. Fever6. Leukocytosis with a left shift

7. ↑

AST/ALT, ↑

TB, ↑

amylase, ↑

lipase

Omar S. Sahagun


Gallbladder & Gallbladder & DuctalDuctal AnatomyAnatomy

Online reference. Virtual Hospital: The apprentice’s assistant.http://www.vh.org

Omar S. Sahagun


Menu of tests for Menu of tests for imaging RUQ painimaging RUQ pain

1. Plain abdominal film

2. RUQ Ultrasound

3. Hepatobiliary Scintigraphy

4. Abdominal CT

Omar S. Sahagun


CT

Salam FZ, MD, FACP, Nezam HA, MD. Clinical Features and Diagnosis of Acute Cholecystitis. 2001 UpToDatePlain film, CT

Omar S. Sahagun


Plain Abdominal FilmPlain Abdominal FilmGallstones often found incidentally on abdominal radiographAbdominal radiographs demonstrate 15-20% of all gallstones– Radio-opaque: calcium bilirubinate– Radiolucent: cholesterol stones

Omar S. Sahagun


RUQ UltrasoundRUQ UltrasoundAdvantages:1. Sensitivity: 96% Specificity: 95%2. Lack of ionizing radiation3. Inexpensive4. Speed, safety, flexibility, & portability5. Real time imaging6. Multiple organ examination

Omar S. Sahagun


NormalGallbladder

Online reference. GE Medical Systems.http://www.gemedicalsystems.com/rad/us/education/msuaa5.html

Normal Gallbladder Ultrasound

http://www.gemedicalsystems.com/rad/us/education/msuaa5.html

Omar S. Sahagun


HepatobiliaryHepatobiliary ScintigraphyScintigraphy –– HIDA ScanHIDA ScanSensitivity: 95% Specificity: 99%Reveals anatomy & physiologic functionMost specific for diagnosing Cystic Duct obstructionTc-99m labeled hepatic iminodiacetic acid (HIDA)IV administration & selective hepatocyte uptake with subsequent excretion into bile– ≈

20% is conjugated and excreted by the

kidneys

Omar S. Sahagun

Gillian Lieberman, M.D. HIDA ScanHIDA ScanOne hour: visualization of gallbladder rules out acute cholecystitis

1-4 hours: delayed visualization– prolonged fasting, pancreatitis, alcoholism,

hepatocellular dysfunction, chronic cholecystitis

> 4 hours: non-visualization of the gallbladder– 95% sensitive and specific for acute cholecystitis

with CD obstruction from edema or a stone

Omar S. Sahagun

Gillian Lieberman, M.D. Morphine Morphine CholescintigraphyCholescintigraphy

Useful in the acute setting, critically ill patients

Differentiates acute from chronic cholecystitis

↑’s sphincter of Oddi pressure → favorable pressure gradient allowing tracer to enter CD

< 30 minutes: chronic cholecystitis

> 30-60 minutes: acute cholecystitis

Omar S. Sahagun


Normal HIDA ScanNormal HIDA Scan

Normal HIDA Scan showing the visualized gallbladder,common bile duct, and filling of the duodenum

Salam FZ, MD, FACP, Nezam HA, MD. Clinical Features and Diagnosis of Acute Cholecystitis. 2001 UpToDate

Omar S. Sahagun


Morphine Scintigraphy: last line shows radioactive tracer uptake by the

gallbladder 20 minutes after the administration of morphineSalam FZ, MD, FACP, Nezam HA, MD. Clinical Features and Diagnosis of Acute Cholecystitis. 2001 UpToDate

Normal

Omar S. Sahagun


Abdominal CTAbdominal CTAdvantages:

High sensitivity

Useful when complications of acute cholecystitisare suspected

Evaluates for a wide range of abdominal diseases so particularly helpful with confusing clinical presentations.

Omar S. Sahagun


Acute Acute CholecystitisCholecystitisConfirmation based upon a combination of physical findings, lab studies, & imaging tests

Characteristic findings on:1. US

a. Cholelithiasisb. + Murphy’s signc. wall thickening (> 4-5mm)d. wall edemaPPV: 92% with + Murphy’s sign & cholelithiasis

Omar S. Sahagun

Gillian Lieberman, M.D. CholelithiasisCholelithiasis

I. Major sonographic criteria1. Echogenic focus2. Acoustic shadowing3. Gravitational dependence

II. CTReveals ≈ 80% of all gallstones

Omar S. Sahagun



Characteristic appearance of Acute Cholecystitis on US

Omar S. Sahagun


thickened gallbladder wall wall-edemaSalam FZ, MD, FACP, Nezam HA, MD. Clinical Features and Diagnosis of Acute Cholecystitis. 2001 UpToDate

Acute Cholecystitis on US

Omar S. Sahagun


Acute Acute CholecystitisCholecystitis on CTon CT

Characteristic findings:Thickened wall with low attenuation areas of edemadistended gallbladder, cholelithiasis, and pericholecystic fluid

Omar S. Sahagun


distended gall bladder with a thickened wallSalam FZ, MD, FACP, Nezam HA, MD. Clinical Features and Diagnosis of Acute Cholecystitis. 2001 UpToDate

Acute Cholecystitis on CT

Omar S. Sahagun


markedly thickened wall due to edema


Acute Cholecystitis on CT

Omar S. Sahagun


Lets introduce our patient:Lets introduce our patient: Clinical PresentationClinical Presentation

CCRUQ pain, SOB

HPI83 year-old moderately obese Caucasian male with an 8-day history of confusion, RUQ pain associated with fevers, poor PO intake, & fatigue

PMHHeavy EtOH abuse, COPD, CAD, afib

Omar S. Sahagun


Differential Diagnosis based on Differential Diagnosis based on clinical observationclinical observation

Common

1. Biliary colic & cholecystic disease

2. Appendicitis3. Dyspepsia/gastritis/PUD4. SBO5. Acute pancreatitis

Uncommon

1. Acute hepatitis2. Right-sided pneumonia3. Fitz-Hugh-Curtis syndrome4. Subhepatic or intra-

abdominal abscess

Omar S. Sahagun


BIDMC Department of Radiology

Our patients RUQ US

No normal GB visualized. Inhomogeneous echogenicity with areas of

distal shadowing noted on region in GB fossa

Omar S. Sahagun



Hyperechoic structure with shadowing

Our patient RUQ US

Omar S. Sahagun


fluid collection with air likely representing an abscess due to a necrotic gallbladder BIDMC Department of Radiology

Our patients abdominal CT

Omar S. Sahagun


Gas in Pericholecystic abscess


Necrotic Gallbladder on CT

Omar S. Sahagun


Our patient has a Necrotic Our patient has a Necrotic Gallbladder with an adjacent Gallbladder with an adjacent

abscess abscess

Omar S. Sahagun


Necrotic GallbladderNecrotic GallbladderIncidence: 2-38% in patients with acute cholecystitis10% of cases associated with perforation– mortality in 19-24% of cases

1. Murphy’s signless common due to denervation of the gallbladder

2. Sonographyasymmetric wall thickening, intraluminalmembranes (sloughed mucosa), striated wall edema

3. Cholescintigraphy – rim signincreased tracer accumulation in the liver parenchyma adjacent to the gallbladder

Omar S. Sahagun


Cholecystostomy drain placement s/p percutaneous drainageBIDMC Department of Radiology

Patient Treatment:

Omar S. Sahagun


Complications of acute Complications of acute CholecystitisCholecystitisCommon in the elderly, diabetics

1.Necrosis (gangrene) & subsequent perforationPatients feel transiently better as bile leaks from the distended gallbladder but rapidly deteriorate if/when bile peritonitis should developLocalized perforation – pericholecystic abscessFree perforation – generalized peritonitis

2.Fistula formation of duodenum & jejunum– Gallstone ileus

Omar S. Sahagun

Gillian Lieberman, M.D. ReferencesReferencesWeltman DI, Zeman, RK. Acute Diseases of the Gallbladder and BiliaryDucts. The Radiologic Clinics of North America 9/94; 32: 933-50.Sturman MF. Acute Abdominal Pain. Effective Medical Imaging: A Sign and Symptoms Approach 1993; 86-108.Rumack CM, Wilson SR, Charboneau JW. The Gallbladder and Bile Ducts. Diagnostic Ultrasound 1998; 1: 175-224.Salam FZ, MD, FACP, Nezam HA, MD. Clinical Features and Diagnosis of Acute Cholecystitis. 2001 UpToDate.Online reference: emedicine. http://www.emedicine.com/emerg/topic621.htmOnline reference. Brigham Radiology. http://www.brighamrad.harvard.edu/Cases/bwh/hcache/96/full.htmlOnline reference. Joint Programs in Nuclear Medicine. http://www.med.harvard.edu/JPNM/TF95_96/Oct31/WriteUp.htmlOnline reference. GE Medical Systems. http://www.gemedicalsystems.com/rad/us/education/msuaa5.htmlOnline reference. Virtual Hospital: The apprentice’s assistant. http://www.vh.org

http://www.emedicine.com/emerg/topic621.htm

http://www.brighamrad.harvard.edu/Cases/bwh/hcache/96/full.html

http://www.med.harvard.edu/JPNM/TF95_96/Oct31/WriteUp.html

http://www.gemedicalsystems.com/rad/us/education/msuaa5.html

http://www.vh.org/

Omar S. Sahagun


AcknowledgementsAcknowledgements1. Gillian Lieberman, MD

2. Chad Brecher, MD

3. Larry Barbaras

4. Cara Lynn D’Amour

5. Beverlee Turner & Pamela Lepkowski

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Cholecystic Cholecystic Disease - Lieberman's eRadiologyeradiology.bidmc.harvard.edu/LearningLab/gastro/Sahagun.pdf · Cholecystic Cholecystic Disease ... Murphy’s sign. z ... A