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Case of the Month

June 2007

Patient Data: 69 year old female

Clinical Info: Pain in the right upper abomen fever and signs of a peritonitis

Longitudinal image of the gallbladder with highly reflective structures within the gallbladder causing acoustic shadowing. The bile ducts are normal.

Longitudinal image of the gallbladder. The wall is thickened, suggestive for a cholecystitis. There are gravity dependent and non gravity dependent echos within the gallbladder.

Transverse image of the gallbladder with sludge and small stones in the gallbladder.

363.swf Abnormal gallbladder

Transverse image of the lowerpole of the liver with peritoneal fluid and reflective structures.

Longitudinal image of the lowerpole of the liver with peritoneal fluid and reflective structures with acoustic shadowing. The highly reflective non gravity dependent echos in the gallbladder and the peritoneal cavity are caused by air.

CT image of the gallbladder showing air within the gallbladder.

CT image showing air in the peritoneal cavity anterior of the liver. There is no air in the intrahepatic bile ducts.

Air and fluid in the peritoneal cavity is fequently caused by a perforation of the digestive tract. In these cases the gallbladder does not contain air.

In this case however there is also an abnormal gallbladder with air in the gallbladder lumen.
Air within the gallbladder can be caused by:
- An ERCP if air is injected together with the contrast.
- An abnormal communication between the biliary tree and the digestive tract for example after a papillotomy, choledochoduodenostomy or gallstone perforation to the digestive tract.
In these cases air is also found in the bile ducts, but in this case the bile ducts are normal.
- An emphysematous cholecystitis.

This patient had an uneventfull medical history. This makes the diagnosis emphysematous cholecystitis the most likely cause for the air in the gallbladder. An emphysematous cholecystitis is caused by an infection with gasforming bacteria. Elderly patients and diabetics have a higher risk. One of the complications of an emphysematous cholecystitis is perforation. In the case of a perforation of an emphysematous cholecystitis, not only fluid but also air can be found in the peritoneal cavity.

Operation confirmed the diagnosis: Emphysematous cholecystitis with small stones, sludge and air in the gallbladder with perforation to the peritoneal cavity.

For more cases see

Bennett GL, Balthazar EJ. Ultrasound and CT evaluation of emergent gallbladder pathology.
Radiol Clin North Am. 2003 Nov;41(6):1203-16. Review.

Copyright © Dr. T.S.A. Geertsma, Ziekenhuis Gelderse Vallei, Ede, The Netherlands. All rights reserved.

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