Hemorrhagic Gangrenous Cholecystitis

Ramin Khorasani, MD
Madeleine D Kraus, MD
Douglas Brown, MD

September 20, 1994

File number: 0

Presentation

Imaging Findings

On initial ultrasound examination two weeks prior to presentation, the gallbladder was normal (arrow) with no evidence of stones.

The second abdominal ultrasound examination shows a markedly thickened gallbladder wall containing a layering echogenic fluid-fluid level.

Computed tomography demonstrates a high attenuation gallbladder wall (short black arrows) containing a layering high attenuation fluid-fluid level (long black arrow, see above link) representing blood or, less likely, pus. There is a small amount of pericholecystic fluid (long white arrow, see above link) as well as inflammatory changes in the fat inferior to the gallbladder (short white arrow, see above link).

Differential Diagnosis

Diagnosis

Discussion

Nontraumatic hemorrhagic cholecystitis is rare. Hemorrhagic holecystitis is most commonly associated with cholelithiasis and has a high mortality rate. The clinical presentation may be indistinguishable from acute cholecystitis. Biliary colic, hematemesis, jaundice, and melena make up the classic, albeit unusual, syndrome. Other presentations include upper gastrointestinal hemorrhage, hydrops of the gallbladder, hemoperitoneum, or obstruction of the common bile duct. This case is atypical in that no stones were present; however, the anticoagulation likely predisposed the patient to hemorrhage.

Although hemorrhagic cholecystitis is thought to represent an earlier and less severe complication of acute cholecystitis, pathologically they often coexist and are difficult to separate by imaging methods. CT may show the higher attenuation of blood. The sonographic findings for hemorrhagic and gangrenous cholecystitis are similar and include focal wall thickening, intraluminal membranes, and non-shadowing, non-mobile intraluminal echogenic material. Urgent cholecystectomy is usually necessary to avoid gallbladder perforation.

Pathology

In acute cholecystitis the gallbladder wall is edematous and is infiltrated by neutrophils; in gangrenous cholecystitis the inflammation is extensive and leads to ischemic infarction of the gallbladder wall. Grossly, the serosa is tan and granular due to transmural inflammation, and the cut surface of the wall may be yellow-tan and soft. The gallbladder may contain clotted blood mixed with bile and stones. Microscopically, the mucosa is eroded, and the wall may be extremely attenuated due to infarction and infiltration by neutrophils.

References

2. Jenkins M, Golding RH, Cooperberg PL. Sonography and computed tomography of hemorrhagic cholecystitis. AJR 1983;140:1197.

3. Laing FC, Federle MP, Jeffrey RS, Brown TW. Ultrasonic evaluation of patients with acute right upper quadrant pain. Radiology 1981;140:449.

4. Escelman DJ, Duva-Frissora AD, Martin LC, et al. Abdominal case of the day. AJR 1991;156: 1304-1305.

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