This case illustrates the classic ultrasound findings of acute cholecystitis – dilated, tender gallbladder, thickened walls and presence of stones. It also discusses a complication of acute cholecystitis that can occur –ascending cholangitis.

This patient had an advanced pancreatic malignancy causing biliary obstruction, superimposed on which she developed acute calculous cholecystitis. This placed her at a high risk for developing cholangitis. Cholangitis is characterized clinically by the triad of jaundice, fever and pain in RUQ. Elevated white cell counts are noted. Cholangitis does not have any specific ultrasound findings. If the ducts are dilated, debris may be visualized as intraluminal echoes. Empyema of the gallbladder may also coexist.

Thus, this was a clinical scenario of an elderly patient presenting with acute calculous cholecystitis [in this case, the patient also had advanced pancreatic malignancy]. Although her biliary findings were related to her pancreatic cancer, the case emphasizes the importance of a thorough evaluation of intra and extrahepatic biliary tree when performing ultrasound of the gallbladder. Furthermore, if cholecystitis is suspected based on sonographic findings, the scan should include an evaluation to exclude complications, including choledocholithiasis, evidence of cholangitis, perforation and pericholecystic abscess.