The lecture overviews the different situations where cholecystitis can be fatal,if not accurately diagnosed.Different types of dangerous cholecystitis are illustrated with their imaging findings.

1. The10 “Dangerous”
cholecystitis.
Dr/Ahmed Bahnassy
Consultant Radiologist -RAFH
MBCHB-MD-FRCR

3. I-Gangrenous Cholecystitis
• Necrotizing.
• Clinical and laboratory criteria are
nonspecific.
• US or CT diagnosis can be life
saving

4. Relative weight of Ct findings

5. CT findings
• air in gallbladder lumen
Intraluminal linear densities
(black arrows) corresponding to
intraluminal membranes. Note
lack of contrast enhancement of
gallbladder wall (open arrow).
Pericholecystic inflammation
(white arrow)

6. • irregularity of wall (black
arrows) of gallbladder (g)
and inflammation in
pericholecystic fat (white
arrow).
• loculated fluid attenuation
abnormality adjacent to gallbladder,
consistent with abscess (a). Defect
in gallbladder wall is shown (black
arrow). White arrow shows
pericholecystic inflammation

7. • markedly distended
gallbladder with irregular wall
showing striated appearance
with alternating areas of high
(black arrows) and low
attenuation (small white
arrow). Large gallstone
(asterisk) is present in
gallbladder lumen. Large
white arrow shows
pericholecystic inflammation.

8. • markedly thickened
gallbladder wall with
alternating areas of high
(black arrows) and low
attenuation (short white
arrow), giving striated
appearance. Gallbladder
wall appears regular and
intact. Note enhancing
vessel in gallbladder wall
(long white arrow).

9. • increased
contrast
enhancement
of liver
parenchyma
adjacent to
gallbladder
fossa
(arrows).

10. • marked
distention of
gallbladder (g)
with mural
thickening
(arrow).

11. • extensive
pericholecystic
fluid (white
arrows).
Intraluminal linear
high density
corresponds to
intraluminal
membrane (black
arrows).

12. II-Emphysematous cholecystitis.
• Emphysematous
cholecystitis is an
unusual but life-
threatening form
of acute
cholecystitis
caused by the
presence of gas-
forming bacteria in
the gallbladder.

13. Pathophysiology
• Emphysematous cholecystitis frequently affects elderly
men, and it is usually associated with diabetes mellitus.
• The risk of gangrene and perforation of the gallbladder is
relatively high for patients with emphysematous
cholecystitis, and the mortality rate is 15%, as compared
with 4% for acute cholecystitis.
• The etiology of emphysematous cholecystitis is
controversial, but it is considered to be due to ischemia
of the gallbladder from primary vascular compromise,
with secondary proliferation of gas-producing bacteria .

14. limited
• Note:
• Wall thickening.
• Pericholecystic
fluid.
• Mural air pocket.
• Fatty stranding.

15. Extensive
• Mural gas
outlining the
gall bladder.

16. US diagnosis..can it be done ?!!

17. III-Gall stone ileus.
• The term classic gallstone ileus often
refers to an obstructing stone localized
to the terminal ileum.
• Delayed diagnosis can be life
threatening.

18. Air in biliary tree
• Air within the
gall bladder or in
biliary
radicles,can
point to fistulous
presence.
• DD portal gas.

19. • Note the gas in
the biliary tree,
and rounded
opacity in the
pelvis

20. Rigler triad
• small bowel
obstruction;
• gas in biliary
tree;
• large ectopic
gallstone

21. Post ERCP

22. IV-Bouveret syndrome.
• Bouveret syndrome
is a gastric outlet
obstruction
produced by a
gallstone impacted
in the distal
stomach or
proximal
duodenum.
• It was described by
Leon Bouveret in
1896 and occurs
most commonly in
elderly women .

23. • Two low
attenuation
stones in gall
bladder and
duodenum.
• Curvilinear
air filled
fistula
between gall
bladder and
2nd part of
duodenum.

24. V-Mirizzi syndrome
• Impaction of a large gallstone (or multiple small
gallstones) in the Hartmann pouch or cystic duct
results in the Mirizzi syndrome in 2 ways:
• (1) Chronic and/or acute inflammatory changes
lead to contraction of the gallbladder, which then
fuses with and causes secondary stenosis of the
CHD, or
• (2) large impacted stones lead to
cholecystocholedochal fistula formation
secondary to direct pressure necrosis of the
adjacent duct walls

25. • Normal CBD.
• Dilated
intrahepatic biliary
radicle.
• Gall bladder stone
disease.
• (DD.:Klatskin
tumour.)

26. VI-Porcelain gall bladder.
• Calcifications
of the gall
bladder wall.
• Precancerous.

27. VII-Haemorrhagic cholecystitis
• The clinical presentation may be
indistinguishable from acute cholecystitis.
Biliary colic, hematemesis, jaundice, and
melena make up the classic, albeit
unusual, syndrome.
• Other presentations include upper
gastrointestinal hemorrhage, hydrops of
the gallbladder, hemoperitoneum, or
obstruction of the common bile duct.

28. When to suspect ?
• Hemorrhage within the gallbladder may
occur secondary to hemobilia from
trauma, biliary neoplasms, vascular
disease including aneurysm rupture into
the biliary tree, ectopic gastric or
pancreatic mucosa, anticoagulation, or
parasites. Spontaneous hemobilia from a
blood dyscrasia is unusual. Ischemia of
the gallbladder of any etiology could result
in hemorrhage secondarily but is rare.

29. • Markedly thickened
gallbladder wall
containing a layering
echogenic fluid-fluid
level high attenuation
gallbladder wall
• CT showing gall
bladder containing a
layering high
attenuation fluid-fluid
level representing
blood or, less likely,
pus .

30. VIII-CCC with Pseudoaneurysm of
cystic artery
• Pseudoaneurysms arise as a
consequence of visceral inflammation
adjacent to the arterial wall, which leads to
damage to the adventitia and thrombosis
of the vasa vasorum resulting in localized
weakness in the vessel wall. These are
prone to rupture.

31. • Cystic artery related pseudoaneurysms may
occur following an episode of acute cholecystitis
or following cholecystectomy. However, in
association with acute cholecystitis
• The rarity of this complication despite the high
incidence of cholecystitis may be due to early
thrombosis of the cystic artery in response to
inflammation .
• It is generally believed that a pseudoaneurysm
develops when a large gallstone erodes the
cystic artery.

32. Ying-Yang sign
• Anechoic lesion
at the gall bladder
neck .
• Color doppler
shows mosaic
appearance of
colours. .
• Produced by to
and fro movement
of blood .

33. Angiography

34. IX-Cholecystitis in ICU patients
• Acalculous Cholecystitis
• Occurs in 0.5 to 1.5% of patients in ICU for
greater than one week
• Patients in intensive care units (ICU) are at
risk of developing acalculous cholecystitis as
a result of a combination of clinical variables.
Patients are usually fasting and are
frequently prescribed medications that cause
cholestasis, which can lead to stasis of biliary
function and acalculous cholecystitis.

35. • Features that have been described: gallbladder wall
thickening, gallbladder distention, intramural gallbladder
wall lucencies (striated gallbladder wall), pericholecystic
fluid, gallbladder sludge, and the presence of a
sonographic Murphy's sign.
• Gallbladder wall thickening was defined as a transverse
wall measurement adjacent to the liver and
perpendicular to the sonography beam of greater than 3
mm.
• Gallbladder distention was defined as a shortaxis
diameter of the gallbladder of 40 mm or greater .
• Gallbladder wall lucencies were defined as irregular
discontinuous lucent and echogenic bands in the
gallbladder wall.

36. • Marked
gallbladder wall
thickening and
pericholecystic
fluid.
• Localized
tenderness could
not be evaluated.

37. • Sagittal
sonogram
reveals
distended
gallbladder .
Note diffuse
anterior
gallbladder
wall lucencies .

38. • Percutaneous
cholecystomy using
the trocar technique.
Ultrasound guides
transhepatic access to
the gallbladder with a
6F trocar drainage
catheter.
• After access, the
catheter is fed forward
to reform the distal
pigtail within the
gallbladder lumen and
is locked in this
configuration.

39. • Ultrasound and CT
studies demonstrate
transhepatic
cholecystomy
catheter in good
position, but interval
development of
markedly worsening
gallbladder wall
edema and
pericholecystic
inflammatory changes
have occurred. At
surgery, gangrenous
gallbladder was found
and resected
successfully.

40. X-Parasitic cholecystitis
• Several parasites infest liver or biliary tree,
either during their maturation stages or as
adult worms. Biliary tree parasites may
cause pancreatitis, cholecystitis, biliary
tree obstruction, recurrent cholangitis,
biliary tree strictures and some may lead
to cholangiocarcinoma.

41. Clonorhiasis associated
cholecystitis
• Clonorchiasis is infection with
the liver fluke Clonorchis
sinensis. Infection is through
undercooked freshwater fish.
• Clonorchis is endemic in the
Far East, especially in Korea,
Japan, Taiwan, and southern
China, and infection occurs
elsewhere among immigrants
and those eating fish imported
from endemic areas.

42. CECT
• IHBR dilatation.
• Hepatic cyst.
• Enhanced GB
wall.
• Intraluminal
stone.
• Eosinophilic
infiltrates with
clonorchisis
ovum.

43. • CT shows hyperdense
material within grossly
distended major
intrahepatic bile ducts,
which on pathological
examination was
proven to be a
combination of
pigmented biliary
stones and sludge and
Clonorchis flukes.
• Several calcified stones
can be seen in
peripheral ducts on this
CT study.
• The spleen is enlarged.

44. Ascariasis induced
• Ascaris lumbricoides, which
causes ascariasis, is the
largest of the round worms
(nematodes), with females
measuring 30 cm x 0.5
cm. It is present in the GI
tract (small intestine) of
1.2–1.5 billion individuals in
tropical and subtropical
areas, making it the most
common nematode
infection in the world.

45. • Intraluminal
tubular filling
defect with +/-
central canal
(GIT)

46. Fascioliasis
• Eggs of Fasciola hepatica have been found in
mummies, showing that human infection was
occurring at least as early as Pharaonic times .
Indeed, F. hepatica was the first fluke or
trematode to be reported.

49. Acute Cholecystitis : How Urgent as Revealed
by CT Signs ?
SUK-PING NG SHE-MENG CHENG SHIN-LIN SHIH
Department of Radiology, Mackay Memorial Hospital

50. Acute Cholecystitis : How Urgent as Revealed by CT Signs ?
SUK-PING NG SHE-MENG CHENG SHIN-LIN SHIH
Department of Radiology, Mackay Memorial Hospital

51. Group I
• Acute
cholecystitis
with a normal
CT.
• Mild
cholecystitis.
• Elective
operation.

52. Group II
• Uncomplicated
acute
cholecystitis.
• Gall bladder
distension with
wall thickening.

53. Group III
• Hyperdense GB
contents,calcium
sludge ,with calcium-
fluid level.
• Operation revealed
He and pus in GB.
• Irregular thickening of
GB(op.:Gangrenous
cholecystitis)

54. Group IV
• Pericholecystic
stranding,intralu
minal
membrane
(OR:acute
gangrenous
cholecystitis)
• Pericholecystic
abscess-
loculated fluid
collection-