Bleeding From the Gallbladder

Abstract

Received February 26, 2007, from the Division of Endoscopy, Yokohama City University Hospital, Yokohama, Japan (N.U.); and Second Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan (S.T.). Revision requested March 26, 2007. Revised manuscript accepted for publication April 13, 2007. Address correspondence to Norio Ueno, MD, Division of Endoscopy, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan. E-mail: nu-1952@io.ocn.ne.jp Abbreviations CEU, contrast-enhanced ultrasonography; CT, computed tomography lthough hemorrhage from the gallbladder is not a common event,1 urgent treatment is required. A case is described herein in which the use of contrast-enhanced ultrasonography (CEU) showed the potential to be a first-line modality for a prompt diagnosis of this entity. A 53-year-old man with right upper abdominal pain was transferred to our emergency department by ambulance. He had a medical history of renal failure and had been receiving chronic hemodialysis for 7 years. He also had a diagnosis of hemophilia A in early childhood. Blood examination showed anemia (hemoglobin level, 8.3 g/dL). Liver enzyme values, including the total bilirubin level, were within normal limits. Ultrasonography showed an enlarged gallbladder with slightly hyperechoic heterogeneous material occupying almost all of the lumen (Figure 1A). A power Doppler ultrasonographic study, which was arranged to detect minute vascular structures, depicted only faint flow signals along the gallbladder wall, suggesting the cystic artery (Figure 1B). To evaluate detailed hemodynamics of the gallbladder, CEU using the intravenous contrast agent Levovist (SH U 508A; Schering AG, Berlin, Germany) was arranged after informed consent was obtained. The instrument used was a commercially available ultrasonography system (Aplio; Toshiba Medical Systems Co, Ltd, Tokyo, Japan) with a 4-MHz curved linear array transducer. Advanced dynamic flow imaging (wideband Doppler imaging) was conducted with a 1.5second intermittent scan. Thirty seconds after injection of Levovist, localized enhancement began to emerge inside the lumen at the neck of the gallbladder (Figure 1C). Because of progressive enlargement of the gallbladder, surgical treatment was conducted 1 week after CEU. Surgical findings involved bloody ascites in the intraperitoneal cavity and an enlarged gallbladder occupied by a massive amount of blood clots. A ruptured cystic artery was identified after the blood clot was removed at the neck portion of the gallbladder lumen. Pathologic findings of the gallbladder showed gangrenous chronic cholecystitis. There were 2 stones impacted into the neck of the gallbladder.