Journal of Emergencies, Trauma, and Shock
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SYMPOSIUM  
Year : 2012  |  Volume : 5  |  Issue : 1  |  Page : 82-83
Sonography of gangrenous cholecystitis


Department of Radiology, Faculty of Medicine, UAE University, PO Box 17666, AL AIN, United Arab Emirates

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Date of Submission13-Feb-2011
Date of Acceptance13-Feb-2011
Date of Web Publication22-Feb-2012
 

   Abstract 

Gangrenous cholecystitis is an acute surgical emergency, which requires early cholecystectomy. Differentiation of patients with gangrenous cholecystitis from those with non-gangrenous cholecystitis can be difficult, both clinically and with imaging. Careful attention to the following sonographic signs suggests the presence of gangrenous cholecystitis decreased focal wall perfusion on Color Doppler, irregular gall bladder mucosal outline, gall bladder wall thickening with signs of de-lamination, gas within the gall bladder, absence of calculi, and large peri-cholecystic collections. Both sonogram with color flow imaging and contrast-enhanced Computed tomography are complementary investigations to establish this important diagnosis in critically ill patients.

Keywords: Cholecystitis, gangrenous, sonogram

How to cite this article:
Corr P. Sonography of gangrenous cholecystitis. J Emerg Trauma Shock 2012;5:82-3

How to cite this URL:
Corr P. Sonography of gangrenous cholecystitis. J Emerg Trauma Shock [serial online] 2012 [cited 2019 Nov 13];5:82-3. Available from: http://www.onlinejets.org/text.asp?2012/5/1/82/93112



   Introduction Top


Gangrenous acute cholecystitis is an uncommon form of cholecystitis, which if undiagnosed, is rapidly fatal. The incidence varies from 2% to 30% in most surgical series of acute cholecystitis. [1] Gangrenous cholecystitis is more likely to occur in older patients, especially men who with cardiovascular disease or diabetes, with an elevated white cell count, viz., greater than 14 900 cells/mm 3 . [2],[3] The clinical diagnosis can be extremely challenging as the differentiation from acute cholecystitis may be very difficult pre-operatively as laboratory and imaging results may be non specific. [4] Murphy's sign of right upper quadrant tenderness on palpation over the distended gall bladder may actually be absent in two thirds of the patients due to the denervation of the gall bladder from necrosis of the wall. [5] For effective management, prompt open cholecystectomy is often the treatment of choice, rather than laparoscopic cholecystectomy. There is an increased prevalence of gall bladder perforation in up to 10% of patients with associated peritonitis, fistula and intra-peritoneal abscess formation. [1],[2] Therefore, it is important to have a high index of suspicion of gangrenous cholecystitis, especially in patients who are diabetic and/or have renal and cardiac impairment. [3],[6],[7] This review emphasizes the value of sonography in the diagnosis of gangrenous cholecystitis and its complementary role with other imaging investigations, especially computed tomography of the upper abdomen.

Early reports using gray- scale sonography found that abdominal sonography was insensitive in detecting gangrenous cholecystitis. Emphasis was placed on detecting a thickened "striated" gall bladder wall as a sign of wall necrosis [Figure 1]. [8],[9] However, this sign is also found in acute cholecystitis and more commonly represents edema of the gall bladder wall rather than necrosis or intramural hemorrhage. Other signs suggesting gall bladder wall necrosis include intra-luminal membranes and asymmetrical wall thickness. [9] Therefore, there is considerable overlap between the sonographic findings of gangrenous cholecystitis and those of cholecystitis: in both conditions, gall bladder wall thickening with "striation" greater than 3 mm occurs, and there is distention of the gall bladder lumen greater than 6 cm in transverse diameter, presence of peri-cholecystic fluid collections and the presence of cholelithiasis. However, Murphy's sign may only be present in one third of the patients with gangrenous cholecystitis compared to over 95% of the patients with cholecystitis. [5] Mok et al., [10] emphasized the loss of the gall bladder mucosa/wall interface echo as a sensitive predictive sign in a small prospective series of 6 patients. With color flow Doppler ultrasound, and along with the ability to visualize and quantify gall bladder wall perfusion, the sensitivity to detect wall necrosis has improved considerably [Figure 2] and [Figure 3]. In gangrenous cholecystitis, focal perfusion defects are present within the necrotic wall of the gall bladder;, this is not present in patients with cholecystitis, where perfusion is actually increased from wall inflammation. This important sign was confirmed by Wu et al., [11] when reviewing Computed tomography (CT) imaging of 25 patients with gangrenous cholecystitis. They found that there was a significant correlation between CT perfusion defects of the gall bladder wall and the presence of gall bladder wall necrosis. The only other CT signs of value were the presence of peri-cholecystic "stranding" of the surrounding fat in the gall bladder fossa and the absence of gall bladder calculi. Radio-nuclide biliary imaging with Technetium 99m di-isoimmino-diacetic acid (DISIDA) can be falsely negative in patients with gangrenous cholecystitis, although a "rim" sign surrounding the gall bladder from peri-hepatic uptake of isotope has also been reported in some patients. [12],[13]
Figure 1: Sonogram of a patient with gangrenous cholecystitis demonstrates a striated irregular thickened gall bladder wall with a calculus in the neck of the gall bladder

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Figure 2: Color flow Doppler sonogram of a patient with gangrenous cholecystitis with absent color flow within the necrotic wall of the gall bladder

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Figure 3: Sonogram of a small peri-cholecystic collection in patients with gangrenous cholecystitis following perforation from wall necrosis

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The initial investigation is sonography with Doppler color flow imaging. This will identify those acutely ill patients will with gall bladder focal perfusion defects, as well as those with the sonographic signs of cholecystitis. To confirm the diagnosis, an un-enhanced and contrast-enhanced CT scan of the abdomen is recommended, especially in the high-risk patient.

 
   References Top

1.Hunt DR, Chu FC. Gangrenous cholecystitis in the laparoscopic era. Aust N Z J Surg 2000;70:428-30.   Back to cited text no. 1
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2. Merriam LT, Kanaan SA, Dawes LG, Angelos P, Prystowsky JB, Rege RV, et al. Gangrenous cholecystitis: Analysis of risk factors and experience with laparoscopic cholecystectomy. Surgery 1999;126:680-5.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Aydin C, Altaca G, Berber I, Tekin K, Kara M, Titiz I. Prognostic parameters for the prediction of acute gangrenous cholecystitis. J Hepatobiliary Pancreat Surg 2006;13:155-9.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Bennett GL, Rusinek H, Lisi V, Israel GM, Krinsky GA, Slywotzky CM, et al. CT findings in acute gangrenous cholecystitis. AJR Am J Roentgenol 2002;178:275-81.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Simeone JF, Brink JA, Mueller PR, Compton C, Hahn PF, Saini S, et al. The sonographic diagnosis of acute gangrenous cholecystitis: Importance of the Murphy sign. AJR Am J Roentgenol 1989;152:289-90.  Back to cited text no. 5
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6.Girgin S, Gedik E, Tacyilidiz I, Akgun Y, Bac B, Uysal E. Factors affecting morbidity and mortality in gangrenous cholecystitis. Acta Chir Belg 2006;106:545-9.  Back to cited text no. 6
    
7.Fagan SP, Awad SS, Rahwan K, Hira K, Aoki N, Itani KM, et al. Prognostic factors for the development of gangrenous cholecystitis. Am J Surg 2003;186:481-5.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Teefey SA, Baron RL, Radke HM, Bigler SA. Gangrenous cholecystitis: New observations on sonography. J Ultrasound Med 1991;10:603-6.  Back to cited text no. 8
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9.Mok PM, Harkness MA, Hayward GK. Loss of the mucosal lining/gall-bladder wall echo: A sonographic sign of gangrenous cholecystitis. Australas Radiol 1994;38:294-7.  Back to cited text no. 9
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10.Jeffrey RB, Laing FC, Wong W, Callen PW. Gangrenous cholecystitis: Diagnosis by ultrasound. Radiology 1983;148:219-21.  Back to cited text no. 10
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11.Wu CH, Chen CC, Wang CJ, Wong YC, Wang LJ, Huang CC, et al. Discrimination of gangrenous from uncomplicated acute cholecystitis: Accuracy of CT findings. Abdom Imaging 2011;36:174-8.  Back to cited text no. 11
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12.Grant RL, Tie ML. False negative biliary scintigraphy in gangrenous cholecystitis. Australas Radiol 2002;46:73-5.  Back to cited text no. 12
[PUBMED]  [FULLTEXT]  
13.Shih WJ, Domstad PA, Kenady DE, DeLand FH. Scintigraphic findings in acute gangrenous cholecystitis. Clin Nucl Med 1987;12:717-20.  Back to cited text no. 13
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Correspondence Address:
Peter Corr
Department of Radiology, Faculty of Medicine, UAE University, PO Box 17666, AL AIN
United Arab Emirates
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.93112

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