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IMPENDING

GALLBLADDER
EMPYEMA
PERFORATION:
A CASE REPORT
Melinda 1, Francisca Notopuro 2, Filipus Michael Yofrido 3, Hans Cendikiawan 4
1 National Hospital, Surabaya, Indonesia
2 Department of Radiology, National Hospital, Surabaya, Indonesia
3 Faculty of Medicine, Widya Mandala Catholic University, Surabaya, Indonesia
4 Department of Radiology, dr. Soetomo Hospital, Surabaya, Indonesia

1.
IMPENDING
GALLBLADDER
EMPYEMA
PERFORATION:
A CASE REPORT

2.
BACKGROUND
Acute
Cholecystitis

Complications6

Empyema Gangrenous Perforation


(5-15%)1,5 (2-20%)4 (8-12%)2

Delay in diagnosis is the major cause of its high


morbidity and mortality.3
3.
CASE REPORT
• A 55-year-old man with history of cholelithiasis
presented to emergency department with
abdominal pain for two days.
• On abdominal examination, he exhibited
positive Murphy’s sign. Other physical
examinations and vital signs are within normal
limits.

4.
CASE REPORT
The laboratory values were as follow:
White blood cell count 17.13 10^3/µL
Direct bilirubin 1.8 mg/dL
Indirect bilirubin 1.3 mg/dL
Total bilirubin 3.1 mg/dL
Quantitative CRP 129.9 mg/L
Pro-calcitonin 37.33ng/mL

AST, ALT, ALP, amylase, and lipase are within


normal limits.
5.
CASE REPORT
1a. Figure 1. (a,b) Grayscale
ultrasound image shows
a dilated gallbladder (4.2
cm on transverse plane)
with wall thickening (8.7
mm), multiple gall
stones (pink arrow)
1b. range diameter 0.26-0.9
cm, and gallbladder
sludge (blue arrow).

6.
CASE REPORT
2a. 2b.

Figure 2. Axial T2-weighted MR image shows a dilated


gallbladder with irregular and thickening of the wall (blue
arrow). There were also multiple gall stones (yellow arrow)
diameters of 6-8 mm and sludge within the gallbladder (pink
arrow). 7.
CASE REPORT
3a. 3b.

Figure 3. (a,b) Axial T2-weighted MR image shows a tracking


and fluid collection in the gallbladder wall (blue arrow)-
secondary to a slight inner wall defect (pink arrow) signifies
an impending perforation. (b) Note the pericholecystic fluid
collection (yellow arrow). 8.
CASE REPORT
3c.

Figure 3. (c) MRCP shows a tracking and fluid collection in the


gallbladder wall (blue arrow)- secondary to a slight inner wall
defect (pink arrow).

9.
CASE REPORT
4a. 4b.

Figure 4. (a, b) A diameter of 8.7mm impacted stone is seen


in the neck of gallbladder (blue arrow).
10.
CASE REPORT
5a. 5b.

Figure 5. (a) Coronal MRCP shows no significance of CBD, CHD, and


IHBD dilatation. (b) Axial T2-weighted MR reveals caliber of the
CBD is 8.2mm, sludge CBD (+), fluid-fluid level (+) (pink arrow).
11.
CASE REPORT
• Urgent laparotomy and cholecystectomy were
performed and revealed that the gallbladder
was filled with 50cc of pus and perforated at the
fundus during surgery.

12.
DISCUSSION
• Complications such as empyema, gangrenous
cholecystitis, and gallbladder perforation have
been reported in 4-12% of all cases of acute
cholecystitis.6
• This patient’s sequence of events that leads to
gallbladder empyema and perforation may
have resulted from his known gallstones.1,6

13.
DISCUSSION
Pathophysiology 5,6
Retention of
Occlusion of the Suppurative
intraluminal
cystic duct infection
secretions

Increase venous Increase


Gallbladder
and lymphatic intraluminal
filled with pus
drainage pressure

Vascular Gallbladder
Necrosis
compromise Perforation

14.
DISCUSSION
• Ultrasound (US) is the first modality to suspected
acute gallbladder disorders, but its result is not
always conclusive.2
• When additional information is needed, magnetic
resonance (MR) imaging, including MR
cholangiopancreatography, can be of help.2
• Multisequence MR images have excellent tissue
contrast and can provide a more comprehensive
and detailed evaluation of the biliary systems.2

15.
CONCLUSION
• Complicated acute cholecystitis often requires
an immediate surgical approach or an
endoscopic interventional approach.
• A potentially fatal complication occurs when
the gallbladder is perforated.
• The radiologist should be aware of the imaging
spectrums that suggest complications of the
acute cholecystitis.

16.
REFERENCES
1. Benjamin Pace, James T O'Connor. Gallbladder Empyema [internet].
Medscape; 2016 [updated Nov 13, 2016]. Available from:
https://emedicine.medscape.com/article/174012-overview
2. Yuji Watanabe, Masako Nagayama, Akira Okumura, Yoshiki Amoh, Takashi
Katsube, Tsuyoshi Suga, Shingo Koyama, Kohya Nakatani, Yoshihiro Dodo.
MR Imaging of Acute Biliary Disorders. RadioGraphic; 2007. Available from:
https://pubs.rsna.org/doi/pdf/10.1148/rg.272055148
3. Hayrullah Derici, Cemal Kara, Ali Dogan Bozdag, Okay Nazli, Tugrul Tansug,
Esra Akca. Diagnosis and treatment of gallbladder perforation. World J
Gastroenterol. 2006 Dec 28; 12(48): 7832–7836. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4087551/

17.
REFERENCES
4. Akın Önder, Murat Kapan, Burak Veli Ülger, Abdullah Oğuz, Ahmet Türkoğlu,
and Ömer Uslukaya. Gangrenous Cholecystitis: Mortality and Risk Factors.
Int Surg. 2015 Feb; 100(2): 254–260. Available
from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4337439/
5. George Mathew, Steve S. Bhimji. Gallbladder, Empyema [internet].
StatPearls Publishing LLC. 2018. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK459333/
6. BS Morris, PR Balpande, AC Morani, RK Chaudhary, M Maheshwari, and AA
Raut. The CT appearances of gallbladder perforation. British Journal of
Radiology. 2014 Jan; 80(959). Available from:
https://www.birpublications.org/doi/10.1259/bjr/28510614

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