Presentation
Abdominal pain and fever for 3 days. Right upper quadrant tenderness on examination and hypotensive.
Patient Data
No radio-opaque gallstones. No gas over the liver to suggest pneumobilia. No bowel obstruction. Bones and lung bases are normal.
Heterogenous echogenicity over the gall bladder fossa with mural thickening and increased vascularity on color doppler. There is a focus of increased echogenicity within the gall bladder lumen but no associated shadowing to indicate calculi.
Distended gall bladder with heterogeneous intra-luminal high-density contents, extensive surrounding peri-cholecystic inflammatory changes and hepatic flexure mural thickening. Foci of hyperdensities within the gall bladder lumen isodense to contrast within the arterial system on arterial phase. No gas within the gall bladder or biliary ducts to suggest fistula to the bowel.
Right basal atelectasis
Cystic artery pseudoaneurysm was confirmed on DSA. Superselection of the cystic artery and subsequent coil embolization of cystic artery pseudoaneurysm. No filling of pseudoaneurysm on post-coiling DSA.
Histology post-cholecystectomy:
Macroscopy:
Specimen labeled gall bladder consists of a perforated and necrotic gall bladder measuring 80 mm x 40 mm x 30 mm.
Microscopy:
Sections of the gall bladder show Rokitansky-Aschoff sinuses, hypertrophy of smooth muscle, fibrosis and mixed inflammatory comprising neutrophils, lymphocytes, plasma cells and macrophages extending to the serosa. No granulomatous inflammation seen.
Overall features are compatible with subacute cholecystitis
Case Discussion
The imaging findings are consistent with hemorrhagic cholecystitis and the patient underwent endovascular coiling of the cystic artery pseudoaneurysm. The patient improved and eventually had cholecystectomy a few weeks later with histology confirming features of subacute cholecystitis.
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