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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.
