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Abdomen » Liver & Biliary System
Complicated acute calculous cholecystitis - with cholangitis
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Presentation An elderly woman with multiple medical problems [including jaundice due to advanced pancreatic head malignancy] presented with pain in the right upper quadrant. A day later, she complained of high grade fevers and had elevated white cell count. An ultrasound performed one week prior to her current complaints showed calculi in the gallbladder with normal wall thickness. The patient had biliary dilatation with a common bile ductal stent in situ.
Caption: Sagittal scan of the gallbladder.
Description: The gallbladder is distended and shows layering of multiple, brightly echogenic calculi which show dense shadowing. The gallbladder wall is greatly thickened [9 mm]. Patient had focal tenderness over the gallbladder while scanning.
Caption: Transverse scan of the gallbladder.
Description: The transverse view shows the thickened gallbladder wall and the lumen filled with multiple gallstones.
Caption: Sagittal scan of gallbladder and part of liver.
Description: The gallbladder is visualized again with its findings of thick wall and calculi. Also noted is intrahepatic pneumobilia [linear echogenic foci following the course of the intrahepatic biliary ducts], secondary to biliary stent placement.
Differential Diagnosis Acute calculous cholecystitis, chronic cholecystitis unlikely in this clinical setting
Final Diagnosis Acute calculous cholecystitis with cholangitis
Discussion The ultrasound appearance of acute cholecystitis has been discussed in a previously published case. [Click here to view the case]

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.

Case References 1. Bedirli A, Sakrak O, et al. Factors effecting the complications in the natural history of acute cholecystitis. Hepatogastroenterology. 2001 Sep-Oct; 48(41):1275-8.
2. Claesson BE. Microflora of the biliary tree and liver--clinical correlates. Dig Dis. 1986; 4(2):93-118.
3. Chock E, Wolfe BM, et al. Acute suppurative cholangitis. Surg Clin North Am. 1981 Aug; 61(4):885-92.
4. Van Assen S, et al. The treatment of gallstone disease in the elderly. Ned Tijdschr Geneeskd. 2003 Jan 25; 147(4):146-50.
5. Nomura T, et al. Enterococcal bactibilia in patients with malignant biliary obstruction. Dig Dis Sci. 2000 Nov; 45(11):2183-6.
6. Sanders RC. The significance of sonographic gallbladder wall thickening. J Clin Ultrasound. 1980 Apr; 8(2):143-6.
Follow Up This patient underwent bile culture which showed purulent material and enterococcus. Due to her multiple medical problems, she was not a surgical candidate and was managed with antibiotics [metronidazole and ciprofloxacin]. Her fevers subsided eventually and the white cell count returned to normal.
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