Slide 1: A 45-year-old woman presents with abdominal pain. Does she require a surgical consultation?

Slide 2: The patient has findings consistent with acute cholecystitis. A surgical consultation is warranted.

Image showing normal gallbladder. Image showing thickened gallbladder wall with dark internal fluid pockets. Image showing internal sludge. Image showing gallstone within the lumen. Image showing color doppler demonstrating increased blood flow in the inflamed gallbladder wall and surrounding parenchyma.

Slide 3: The patient worsens and a CT of the abdomen is obtained. What complication of cholecystitis is identified?

CT scan of patients abdomen. This patient’s gallbladder is surrounded by significant fat stranding but also shows the internal mucosa beginning to slough off. This is worrisome for gangrenous cholecystitis. These patients, often diabetic with atypical presentations, are VERY sick and require urgent surgical consult as mortality rates are high. Similarly, gas in the gallbladder wall can be seen in emphysematous cholecystitis with similar patient populations and high complication rates.

Slide 4: Which imaging modality is best to evaluate suspected cholecystitis? The ACR Appropriateness Criteria rates ultrasound as the the most appropriate initial evaluation for acute cholecystitis due to accuracy (sens/spec 88%/80%), rapidity, ability to identify complications and the lack of radiation to the patient.

The combination of stones visualized within the gallbladder and a positive sonographic murphy’s sign on exam has a 92% sensitivity for cholecystitis.

The only modality to show improved accuracy of detection was the HIDA scan (sens/spec 97%/90%). This is a good next step if ultrasound is equivocal, but takes a lot longer.

CT isn’t as good at finding stones and MRI takes too long.

Slide 5: Let’s review! Imaging considerations in evaluation of acute cholecystitis. What is the imaging modality of choice? Ultrasound. Can perform HIDA scan if equivocal findings.

What are key imaging characteristics? Gallstones, sonographic murphy sign. Dilation, wall edema and color flow.

Which complications are identified with imaging? Emphysematous and gangrenous cholecystitis. Atypical presentations with high mortality.