Radiological Category: Gastrointestinal
Principal Modality (1): CT
Principal Modality (2): Chest X-ray
Case Report
Submitted by:
Pavit Bains, MS4
Faculty reviewer:
Sandra Oldham, M.D.
Date accepted:
26 August 2010
Case History
The patient is an 80-year-old Hispanic male with past medical history of
hypertension, diabetes who had been experiencing midepigastric pain, as well
as right upper quadrant pain starting about 2 days ago. States the pain is dull
and constant in nature, of mild-to-moderate intensity, slightly exacerbated with
eating. No known alleviating factors. In addition, the patient states he has had
subjective fevers for 2 days. Denies any nausea or vomiting. However, he does
admit that he has had decreased appetite. No known travel or recent sick
contacts.
Radiological Presentations
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• Pneumatosis Intestinalis
• Emphysematous Cholecystitis
• Intra-abdominal abscess
• Cholecysto-enteric fistula
• Gallbladder lipomatosis
Findings and Differentials
Findings:
DISCUSSION: The lungs are mildly underinflated. No focal
consolidation is seen. The heart size is normal. The bones are intact.
IMPRESSION: No acute abnormality is visualized.
Linear lucency in the wall of a tubular structure.
Osteophytes and evidence of degenerative disease.
Differentials:
• Pneumatosis Coli
• Emphysematous Coli
• Intra-abdominal abscess
• Cholecysto-enteric fistula
Discussion
•
Cholecystoenteric fistulas are a rare complication of gallstone disease and 3–
5% of patients with cholelithiasis are affected.
•
Chronic cholecystitis is the primary etiology in as many as 75% of CF patients.
Cholecystoduodenal type accounts for 80% of CF
•
Pathogenesis:
Stone formation occurs in the gallbladder and may lead to subsequent
obstruction of the cystic duct (cholecystitis). This acute inflammatory
process may result in adhesion of the gallbladder to a contiguous viscus,
(usually duodenum).
•
Recurrent episodes of such inflammation result in the destruction of the wall of
the gallbladder and the adjacent viscus, ultimately resulting in erosion of the
tissues and fistulation. An alternative theory suggests that the mechanical
pressure due to a gallstone results in erosion of the tissues in the gallbladder
wall with necrosis until a fistula forms with the contiguous viscus
Discussion
•
Pneumobilia seen on imaging studies strongly suggests the presence of an
internal biliary fistula in the absence of prior sphincterotomy, recent
endoscopic retrograde cholangiopancreatography, or passed common duct
stone.
•
An atrophic gallbladder adherent to neighboring organs seen on CT scan may
also elude to a cholecystoenteric fistula. CT can also provide important
information on the degree of bowel obstruction and suggest the likely site of
fistula formation in the case of gallstone ileus.
Discussion
•
ERCP was the most valuable diagnostic method for direct visualization of a
biliary-enteric fistula.
•
Conventional contrast-enhanced GI studies are a less direct method for fistula
demonstration. However, they are relatively noninvasive and may help detect
an unsuspected communication with the biliary tree.
Cholecystoenteric
fistula
Discussion
•Intra-abdominal abscess - infected pocket of fluid and pus located inside the
abdomen.
•An intra-abdominal abscess can be caused by a ruptured diverticula, ruptured
appendix, a parasite infection in the intestines, perforated ulcer disease, or any
surgery that may have infected the abdominal cavity
•Symptoms may include: Abdominal pain and distention, chills, diarrhea, fever,
loss of appetite, nausea, vomiting, weakness
•Microbiology includes a mixture of aerobic and anaerobic organisms. The most
commonly isolated aerobic organism is Escherichia coli, and the most common
anaerobic organism is Bacteroides fragilis
Discussion
• Abnormalities on plain abdominal films may include a localized ileus,
extraluminal gas, air-fluid levels, mottled soft-tissue masses, absence of psoas
outlines, or displacement of viscera.
• In subphrenic or even subhepatic abscesses, the chest radiograph may show
pleural effusion, basilar infiltrates, elevated hemidiaphragm, or atelectasis.
•CT scans can document inflammatory edema in the adjacent fat (obliteration of fat
plane) and enhancement in the abscess wall.
Intra-abdominal
Abscess
Discussion
•Pneumatosis intestinalis is a rare condition characterized by multiple gas-filled
cysts within the bowel wall.
•PI typically presents in the fifth to eighth decade for adults and is idiopathic (15
percent) or secondary (85 percent) to a wide variety of gastrointestinal and nongastrointestinal illnesses
•Primary pneumatosis intestinalis (15% of cases) is a benign idiopathic condition
in which multiple thin-walled cysts develop in the submucosa or subserosa of the
colon.
–Usually, this form has no associated symptoms
–Cysts may be found incidentally through radiography or endoscopy.
Discussion
•Secondary pneumatosis intestinalis is associated with obstructive and necrotic
gastrointestinal disease, as well as with obstructive pulmonary disease
–Bowel necrosis leading to pneumatosis is seen in necrotizing enterocolitis (NEC),
mesenteric ischemia, and caustic ingestions.
–In the absence of bowel necrosis, many gastrointestinal diseases resulting in obstruction
or ulceration can lead to pneumatosis intestinalis.
• Pneumatosis can be seen in pyloric stenosis and Hirschsprung disease in children,
• Bowel obstruction in adults
–Pulmonary diseases - severe obstructive pulmonary disease may result in pneumatosis.
Rupture of pulmonary blebs in obstructive lung disease may cause air to dissect through
the retroperitoneum, into the mesentery, and, finally, to the bowel subserosa.
Pneumatosis
Intestinalis
Diagnosis
•
Emphysematous Cholecystitis*
Emphysematous cholecystitis is an acute infection of the gallbladder wall caused by
gas-forming organisms. It is a rare form of acute cholecystitis
Four pathogenetic factors are proposed in the development of emphysematous
cholecystitis.
1. Vascular compromise of the gallbladder
2. Gallstones
3. Impaired immune protection
4. Infection with gas-forming organisms
Diagnosis
Emphysematous Cholecystitis
Stage 1 emphysematous cholecystitis is characterized by gas within the
gallbladder lumen;
Stage 2 - gas with in the gallbladder wall;
Stage 3 - gas within the pericholecystic tissues
Diagnosis
Abdominal plain film:
Gallbladder wall containing gas. The gallbladder is often fluid-filled, and gas may leak
into the lumen.
Inflammation and gas formation may extend to the pericholecystic tissues and
extrahepatic ducts.
CT:
Emphysematous changes in the gallbladder wall that are diagnostic of this
condition. May include gallbladder wall thickening >3mm, cholelithiasis,
increased density of bile (>20 H), pericholecystic fat stranding, air-liquid level
within gallbladder lumen
Treatment: Antibiotics and Fluids to stabilize the patient followed by prompt surgical
procedures to prevent perforation.
Interventional radiologic techniques allow drainage and decompression followed by
excision of gallbladder.
Emphysematous
Cholecystitis
Emphysematous
Cholecystitis
References
1. S. R. Martinez, H. S. Hourani, J. J. Sorrento & E. P. Mohan : Emphysematous
Cholecystitis: A Case Report and Literature Review . The Internet Journal of Surgery.
2005 Volume 6 Number 2
2. Wen-Ke Wang, Chun-Nan Yeh, Yi-Yin Jan: Successful laparoscopic management for
cholecystoenteric fistula. W J Gastroenterol 2006 , 12(5):772-775. OpenURL
3. PickhardtPJ, Bhalla S, Balfe DM. Acquired gastrointestinal fistulas: classification,
etiologies, and imaging evaluation. Radiology2002; 224(1): 9–23.
4. Grayson DE, Abbott RM, Levy AD,et al. Emphysematous infections of the abdomen
and pelvis: a pictorial review. Radiographics 2002; 22: 543–61.