From the RSNA Refresher Courses

Abstract

Acute cholecystitis is the most common cause of acute pain in the right upper quadrant (RUQ), and urgent surgical removal of the gallbladder is the treatment of choice for uncomplicated disease. However, cross-sectional imaging is essential because more than one-third of patients with acute RUQ pain do not have acute cholecystitis. In addition, patients with complications of acute cholecystitis, such as perforation, are often best treated with supportive measures initially and elective cholecystectomy at a later date. Ultrasound (US) is the primary imaging modality for assessment of acute RUQ pain; US is both sensitive and specific in demonstrating gallstones, biliary dilatation, and features that suggest acute inflammatory disease. Occasionally, additional imaging modalities are indicated. Computed tomography is valuable, especially for confirming the extent and nature of the complications of acute cholecystitis. Magnetic resonance cholangiopancreatography is helpful in complicated ductal disease (eg, recurrent pyogenic cholangiohepatitis) when more detailed diagnostic information is required for treatment planning, whereas endoscopic retrograde cholangiopancreatography is used when biliary intervention is required (eg, treatment of choledocholithiasis). Successful imaging with all modalities requires familiarity with both the characteristic and the unusual features of a wide variety of pathologic conditions. In addition, potential pitfalls must be recognized and avoided.

The Bouveret’s Syndrome: A Case Report of a Rolling Gallstone from the Gallbladder to the Duodenum

“…This rare condition, affecting 0.9% -3.2% of patients with biliary disease [3], is due to the close anatomic relationship between the gallbladder and the duodenum and the proximal transverse colon. As a result, chronic inflammation of the gallbladder may lead to chronic perforation and fistulous communication to these structures [4]. In a series of 10 patients Oikarinen et al [5] demonstrated that acute or chronic cholecystitis is a significant predisposing factor of internal biliary fistula and that, as it happened in the case described above, the most frequent is the cholecysto-duodenal type.…”

“…This latter may be seen if the tract is enhanced by positive oral or air contrast material. A secondary sign that may be useful is the identification of oral contrast material within the gallbladder [4] [7]. One potential drawback of CT is that 15% -25% of gallstones appear as isoattenuating relative to bile or fluid.…”

“…It consists in a gastric outlet obstruction due to the development of an internal biliary fistula and the migration of gallstones from the gallbladder to the bowel [4] [5]. Once the gallstone passes in the duodenum, it may cause a mechanical obstruction at the level of the ileum, or less commonly, a gastric obstruction.…”

Spectral CT Detection of Entrapped Gallstone Based on Z-effective Map

“…In the daily practice, US is still the primary imaging modality when GBS and acute cholecystitis are suspected [1,2]. In an acute setting, doubtful or difficult cases on US are evaluated additionally with CT [10].…”

Differentiation of acute cholecystitis from chronic cholecystitis

“…Acute cholecystitis occurs in about one-third of patients with acute right upper quadrant (RUQ) pain, [ 1 ] which can also occur in various diseases, including chronic cholecystitis, acute pancreatitis, diverticulitis, colitis, appendicitis, Fitz-Hugh-Curtis syndrome, ureteral stone, and omental infarction. [ 2 ] In 1 study of patients with acute RUQ pain, only about one-third had acute cholecystitis (34.6%), while others had chronic cholecystitis (32.7%) or a normal gallbladder (32.7%).…”