Presentation
Acute abdomen, right hypochondrium pain and vomiting
Patient Data
Note: This case has been tagged as "legacy" as it no longer meets image preparation and/or other case publication guidelines.
The gall bladder is distended and shows evidence of T2 hyperintense sludge and bile. There is evidence of dependently located multiple signal voids. This signal void shows mobility with movement towards dependent portion of the gall bladder while scanning with prone position - thus confirming gall bladder calculi. Largest of these calculi measure up to 10mm to 12mm.
The wall of GB is markedly thickened measures up to 8mm to 13mm.
There is evidence of multiple linear intramural T2 hypointense foci within the gall bladder lumen which are likely to be indicating intramural herniation of the gall bladder mucosa (Rokitansky-Aschoff sinuses) - suggestive of diffuse adenomyomatosis of the gall bladder (also confirmed and correlated with ultrasound).
CBD measures 5.2mm and shows normal gradual distal tapering. The common bile duct appears normal in caliber and the confluence of the right and left hepatic ducts is seen normally. The intrahepatic biliary radicles appear normal in caliber.
The pancreatic duct shows normal configuration and appearance and is joining CBD before opening into ampulla of Vater.
The proximal cystic duct is normal in caliber; however, there is evidence of fusiform dilatation of the mid portion of the cystic duct where it measures up to 24mm. The distal cystic duct is normal in caliber and is opening into CBD roughly at 7 o'clock position. A vessel is seen crossing the cystic duct at the level of the distal transition of the dilated portion of cystic duct into normal mucosa.
There is evidence of very minimal peri-cholecystic fluid.
Peripancreatic fat planes are normal.
The opposite phase imaging reveals diffuse fatty infiltration of liver.
IMPRESSION:
MR findings are consistent with
- cholelithiasis with acute cholecystitis with status as described above
- fusiform diverticulum like dilatation of the mid-portion of cyst duct is noted with features as described - suggestive of cystic duct diverticulum
Clinical correlation is recommended.
Case Discussion
This case shows features of adenomyomatosis of the gallbladder and its MRCP appearance.
The case also demonstrates all the features of acute cholecystitis and cholelithiasis as seen in MRCP.
There is evidence of fusiform type of cystic duct diverticulum.
The Todani classification describes only 5 types of choledochal cyst abnormality. The diverticulum dilatation of the cystic duct has not been described by Todani. However, there are some sporadic case reports and a series of 10 cases of this entity. The significance of this entity is in surgical planning. Allowing a preoperative diagnosis of this condition may warn the surgeon and avoid potential complications. There may be other long-term significance of this condition, however, this needs to be investigated by appropriate studies.
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