MyPACS.net: Radiology Teaching Files > Case 48201994

Last visited 11-15-2010 GALLBLADDER
Contributed by: Rebecca Kessler, Resident, Brooke Army Medical Center, Texas, USA.
History: 80 yr old male with vague right upper quadrant pain. Patient first received CT scan secondary to vague abdominal complaints at presentation.
Images:[small]larger

Fig. 1: CT abdomen demonstrating periportal edema.

Fig. 2

Fig. 3: Coronal CT image demonstrating periportal edema causing 'focal wall' thickening of adjacent gallbladder wall. Note the remaining gallbladder wall has normal wall thickness.

Fig. 4: Questionable gallbladder wall thickening along liver edge.

Fig. 5: No gallbladder seen on frontal view.

Fig. 6: No gallbladder seen on lateral view.

Fig. 7: Percutaneous cholecystostomy tube placement demonstrates hydropic gallbladder without evidence of bowel wall thickening.

Fig. 8

Fig. 9: Different patient demonstrating normal activity in gallbladder and bowel.

Fig. 10: Different patient: Normal lateral view with activity noted within gallbladder.
Findings:

CT demonstrates periportal edema and questionable gallbladder wall thickening. Calcification near the neck of the gallbladder/cystic duct.

Ultrasound again demonastrates possible gallbladder wall thickening adjacent to liver parenchyma.

Hepatabiliary scan demonstrates no activity within the gallbladder after 60 minutes and administration of morphine.

Percutaneous cholecystomy tube placement demonstrates no evidence of bowel wall thickening.

 

Diagnosis:

Hydrops Gallbladder

After positive hepatobilliary scan with no activity noted within the gallbladder, the patient was taken to the interventional radiology suite for drainage because patient not a good surgical candidate. A fluroscopic guided percutaneous placement of cholecystomy tube demonstrated mucoid content without evidence of infection. Images demonstrate smooth gallbladder walls without evidence of inflammation.

This case demonstrates the importance of including hydrops in the differential on a positive hepatobilliary scan.

It also shows that periportal edema and ascites can cause gallbladder wall thickening.

Discussion:

Hydropic Gallbladder (Mucocele)

Right upper quadrant pain has a long list of possible causes to include but not limited to acute and chronic cholecystitis, choledocholithiasis, pancreatitis, peptic ulcer disease, acute hepatitis, liver abscess, liver neoplasm with complication, pneumonia, and heart disease.

Diagnosis:

Workup for right upper quadrant general begins with ultrasound to evaluate for gallbladder wall thickening, pericholecystic fluid, gallstones, biliary ductal dilitation and positive Murphy's sign. Remember periportal edema and abdominal ascites can cause gallbladder wall thickening in the absence of gallbladder disease.

Hepatobiliary study maybe used to assess for acute or chronic cholecystits; however, false positive may also be seen with hydropic gallbladder (mucocele) or gallbladder/liver mass that causes lack of filling of the gallbladder.

The diagnosis of a mucocele should be considered in the following:

  • Minimal acute inflammatory signs
  • Large, palpable, minimally tender gallbladder on clinical examination.
  • Laboratory test results are normal or within the upper limit of normal
  • Plain radiograph of the abdomen shows a soft-tissue–density, globular shadow in the subhepatic region
  • Ultrasonography of the RUQ shows evidence of minimal wall thickening, an impacted stone in the neck, or infundibulum of an enlarged gallbladder and clear content
  • Intraoperatively, the aspirate from the gallbladder is clear and watery or mucoid (white bile)
  • Resected gallbladder on opening shows a white wall, clear and watery or mucoid content, a stone or stones impacted in the neck or cystic duct, a narrowed cystic duct, or a tumor and/or polyp causing obstruction of the neck of the gallbladder.  EMEDICINE.

Pathogenesis:

Secondary to long-standing obstruction to gallbladder's outflow resulting in overdistention of gallblader. Gallbladder contents usually sterile, but if infected forms emypyema of gallbladder. Longstanding case causes thinning of wall; however, recurrent cholecystitis may thicken the wall.

Potential causes: impacted stone in gallbladder neck or cystic duct, spontaneously resolved acute cholecystitis, polyps or malignancy of the gallbladder, extrinsic compression of neck or cystic duct by lymph nodes or inflammation/fibrosis or malignancy in adjacent organs, prolonged TPN or ceftriaxone therapy, congenital narrowing of cystic duct, parasites (ascaris)


Signs and symptoms:

Right upper quadrant or epigastric pain/discomfort, nausea and vomiting.

If pain/tenderness > 6 hours favor acute cholecystitis.

Fever and chills suggest infected bile and possible empyema of gallbladder

Palpable mildly tender mass in the right upper quadrant.


Treatment:

Surgery; however, may be contraindications in some medical conditions. No absolute contraindication exists.

Chemical ablation of the gallbladder mucosa might be an alternative in patients who are medically unfit, elderly, or critically ill. Combination of ethanol, sodium tetradecyl sulfate, and mucosal exfoliant has been successfully tried in rats.

 

Hepatobiliary (IDA) Scan or Cholescintigraphy Indications          

  • To diagnose suspected acute cholecystitis
  • To investigate possible biliary obstruction
  • To detect biliary leak
  • To differentiate biliary atresia from neonatal hepatitis
  • To diagnose biliary dyskinesia
  • To confirm the presence of a choledochal cyst

Radionuclide diagnosist imaging study that evaluates hepatocellular function and patency of the biliary system. It follows the production and flow of bile from liver and through biliary system into the small intestine.

Procedure:

Patient should have fasted for minimum of 2 but preferrably 4 hours. If patient has fasted for longer than 24 hours or is on TPN the patient may be pretreated with sincalide (this empties the gallbladder so it can fill with radiopharmaceutical).

Attention should be paid to recent medications such as opoids (best to do procedure 4 hours after last dose).

Tc-99m labeled DISIDA or BRIDA is then administered IV with doses ranging from 1.5-5 mCi in adults (higher doses may be required in hyperbilirubinemia 3-10 mCi). Infants and children may be given 0.05-0.2 mCi/kg with minimum of 0.4-0.5 mCi.

Large field of view, Low energy all-purpose or high-resolution collimater.

Imaging (frontal view) begins at injection and serially for 60 minues or until activity noted in gallbladder and small bowel. Additional right lateral, left or right anterior oblique views may also be obtained to clarify anatomy.

Findings:

In setting of suspected acute cholecystitis, if gallbladder not seen within 60 minutes Morphine augmentation or delayed 4 hour images may be obtained to visualize the gallbladder. If gallbladder activity noted after augmentation or delay then diagnosis of chronic cholecystitis is suggested. IF no activity noted in gallbladder after delay or augmentation acute cholecystitis suggested but differential also includes other causes of bile obstruction to the gallbladder.

References:

Gallbladder Mucocele. http://emedicine.medscape.com/article/195165-overview

Imaging Evaluation for Acute Pain in the Right Upper Quadrant. http://radiographics.rsna.org/content/24/4/1117.full.pdf+html?sid=c5f4d459-89d0-4646-8811-c1a891572235

Taylor, Andrew; Schuster, David M; Alzaraki, Naomi. A Clinician's Guide to Nuclear Medicine. http://interactive.snm.org/index.cfm?PageID=1608

Society of Nuclear Medicine Procedure Guideline for Hepatobiliary Scintigraphy version 3.0, approved June 23, 2001. http://interactive.snm.org/docs/pg_ch11_0703.pdf

 

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Additional Details:

Case Number: 48201994Last Updated: 11-15-2010
Anatomy: Gastrointestinal (GI)   Pathology: Non-Infectious Inflammatory Disease
Access Level: Readable by all users
Keywords: hydropic gallbladder, cholecystitis

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