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The following is a 25-year-old gentleman who presents

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with increased liver function enzymes, and so they

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wanted to get a CT scan liver mass protocol to

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evaluate the cause of these findings, and we'll start

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scrolling through and seeing what we find over here.

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So this is a young patient.

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And focus on the gallbladder,

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start off with a non-contrast image.

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You can see the gallbladder over here.

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Looks a little bit distended, but even on the

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non-contrast image, you get the sense that the fat

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around this gallbladder looks very inflamed.

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A lot of fat stranding over here certainly

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looks more hyperattenuating than any of

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the fat in this patient's abdominal cavity.

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So there's something going on in the right upper quadrant.

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It looks like it's centered around the gallbladder.

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So we get contrast.

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We have the arterial phase images over here.

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You can see already that there's

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some gallbladder wall edema.

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Now that's not a specific sign for acute cholecystitis.

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There are several causes of gallbladder wall edema.

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But it indeed is a sign that can

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be seen with acute cholecystitis.

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So, that's one potential sign

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surrounding the gallbladder.

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In this image, you can see all this

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fluid and fat stranding that is sort of

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centered around that right upper quadrant.

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More inferiorly, again, lots

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of fluid and fat stranding.

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And so, when you sort of see these signs, um,

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you start to get really worried about acute cholecystitis.

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If you were to look at the liver parenchyma

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adjacent to this patient's gallbladder, um, again,

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you can see that hyperemia that's sort of just

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surrounding this gallbladder, telling you that

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potentially this gallbladder is inflamed.

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So, sort of, putting all this together, I would

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certainly raise my suspicion for acute cholecystitis

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based on these sets of images so far.

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Now, one of the reasons I wanted to show

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this case is that, you know, we've seen

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what acute cholecystitis looks like.

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This has the imaging appearance of it, but once

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we've sort of established that we think the patient

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has acute cholecystitis, it becomes very important

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to start looking for some of the complications.

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So one of the complications I want to show you

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is that is, uh, I think, relatively subtle in this instance,

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but it bore out to be true.

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I want you to sort of look at the

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gallbladder wall, the mucosa itself.

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It's relatively hyperemic and enhancing

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as you would expect, and as you sort

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of follow it downwards, over here,

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you can sort of follow it, follow it nicely.

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And even here, you can trace it relatively

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nicely, but right about here on this slice,

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you can trace it nicely over here, nicely

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over here, nicely over here, nicely over here.

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And then from about, if we consider this a

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clock, maybe from like eight o'clock to

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12 o'clock, there's a portion of that gallbladder

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wall that's just not enhancing, right?

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And it's a persistent finding across many slices here.

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69 00:02:45,700 --> 00:02:46,900 Over here, it's enhancing.

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Over here, it's not enhancing.

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We can see, uh, you know, we did this as a

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liver mass protocol, so we can see on different

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phases that this finding will be consistent.

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Again, enhancing relatively nicely.

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And as, again, you get to this portion here,

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there's poor enhancement of that gallbladder wall.

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If you look at it on the coronal images, this is

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a coronal, the arterial phase, you can see that

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the gallbladder wall is enhancing relatively

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nicely for the most part over here and over here.

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And as you get to sort of the fundus of that

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gallbladder, there is an abrupt change where you really

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don't see that gallbladder wall enhancing very nicely.

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And so when you have that instance where you

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have acute cholecystitis, but the wall,

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the mucosa of the gallbladder shows areas that are

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not enhancing, you have to be worried about

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gangrenous cholecystitis.

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It's one of the more common complications

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seen with acute cholecystitis.

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In some reports, up to 15% of patients

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with acute cholecystitis will have

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gangrenous cholecystitis as a complication.

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And as its name implies, it is essentially ischemia

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of the gallbladder wall with

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resulting necrosis of the gallbladder wall itself.

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Now from a clinical perspective, it's important

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to know that these patients with gangrenous

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cholecystitis may have atypical symptoms in that

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their Murphy sign may be absent, and that's thought

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to be due to ischemic denervation of the gallbladder.

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Typically, this is a finding that's seen

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more often with patients who have diabetes.

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It's important to know about this complication

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because the overall mortality rate of gangrenous cholecystitis

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is higher than just simple acute cholecystitis.

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Key thing you have to look for in

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all patients with acute cholecystitis

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is the gallbladder wall enhancement.

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If it's missing, you have to raise the

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possibility of gangrenous cholecystitis.

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That possibility was raised in this instance.

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The gallbladder was taken out and it was

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indeed found to have gangrenous cholecystitis.