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Age: 73

Sex: Female

Indication: Right-sided abdominal pain

Sonographic Murphy sign: Positive

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Case #27


Findings

  • Gallbladder is mildly distended with wall thickening and possible trace pericholecystic fluid
  • No gallstones
  • Liver is enlarged, measuring 21.8 cm in craniocaudal span, with diffusely increased parenchymal echogenicity
  • Patent portal and hepatic veins with antegrade flow
  • No intrahepatic or extrahepatic biliary duct dilation
  • Normal appearance of the right kidney and of the visualized portion of the pancreas
  • Visualized portions of the abdominal aorta are normal in caliber
  • No ascites


Diagnosis

Acalculous cholecystitis

Sample Report

Gallbladder is mildly distended with wall thickening and possible trace pericholecystic fluid. Given a positive sonographic Murphy sign and in the absence of gallstones, these findings raise concern for acalculous cholecystitis.

Hepatomegaly with hepatic steatosis.


Discussion

  • Acalculous cholecystitis is often a challenging diagnosis because it typically occurs in critically ill patients with polysystemic disease and has less reliable imaging findings than calculous cholecystitis
  • Ultrasound and CT findings supportive of the diagnosis are the same as those for calculous cholecystitis (gallbladder wall thickening, distension, pericholecystic fluid/inflammatory change) with the exception of an obstructing calculous in the gallbladder neck or cystic duct
  • A positive sonographic Murphy sign is useful when present, but often challenging to assess in critically ill patients and not required for the diagnosis
  • The diagnosis of acalculous cholecystitis can still be made in the presence of gallstones if the gallstones are thought to not be causing gallbladder outflow obstruction
  • Nuclear medicine cholescintigraphy may be helpful in ambiguous cases



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