Septic Shock and Abdominal pain • Xray of the Week 2018
A 57 yo M presented to the Emergency Department with septic shock and vague abdominal pain. What is the diagnosis and what is the treatment of choice?
Figure 1. (A) Axial non-contrast CT of the upper abdomen. (B) Gallbladder ultrasound.
Figure 2. (A) Axial non-contrast CT of the upper abdomen. (B) Gallbladder ultrasound. Red arrow: Thick-walled gallbladder with surrounding mesenteric fat stranding indicative of acute cholecystitis seen on CT scan. Green arrow: Edema in thickened gallbladder wall seen on ultrasound.
Figure 3. CT images following placement of cholecystostomy tube (Green arrow).
Acute cholecystitis is the main complication of gallstones and is a common cause of acute right upper quadrant pain. While the vast majority are associated with gallstones, 5-10% of cases are due to acalculous cholecystitis. As in this case, if there are no gallstones, the diagnosis of acute acalculous cholecystitis can be suggested if there is gallbladder wall thickening and surrounding edema (Fig. 1-2). Adjacent fluid, abscess, and positive ultrasonographic Murphy sign may also be present. Severe trauma, critical illness, burn, diabetes, malignant disease, abdominal vasculitis, congestive heart failure, cholesterol embolization, shock, and cardiac arrest are all associated with acute acalculous cholecystitis.
The most common indication for percutaneous cholecystostomy is with cases of known cholecystitis -either calculous or acalculous- in patients who are too high risk for surgery. However, the procedure should be considered in critically ill patients with unexplained sepsis. Complications of the procedure include bile leak, bleeding, and bowel injury. The most common cause of bile leak and recurrent sepsis is catheter dislodgement, which is why it is advised to coil the tube inside the gallbladder if possible.
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2. Mirvis SE, Vainright JR, Nelson AW et-al. The diagnosis of acute acalculous cholecystitis: a comparison of sonography, scintigraphy, and CT. AJR Am J Roentgenol. 1986;147 (6): 1171-5.
3. Joseph T, Unver K, Hwang GL et-al. Percutaneous cholecystostomy for acute cholecystitis: ten-year experience. J Vasc Interv Radiol. 2012;23 (1): 83-8.e1.
4. Huang CC, Lo HC, Tzeng YM et-al. Percutaneous transhepatic gall bladder drainage: a better initial therapeutic choice for patients with gall bladder perforation in the emergency department. Emerg Med J. 2007;24 (12): 836-40
Kevin M. Rice, MD is president of Global Radiology CME and serves as the Chief of staff and Chair of the Radiology Department of Valley Presbyterian Hospital in Los Angeles, California and is a radiologist with Renaissance Imaging Medical Associates. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. Dr. Rice co-founded Global Radiology CME with Natalie Rice to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" award for the Most Effective Radiology Educator.
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