Gangrenous Cholecystitis Missed on Imaging

Abstract

Despite advances in the radiologic investigations, the diagnosis of acute cholecystitis is still challenging. A delay in recognizing and treating an inflamed gallbladder may increase the risk of necrosis and subsequent complications. This report sheds light on the limitations of diagnostic testing and clinical signs in the diagnosis of acute cholecystitis. A 77 year-old male patient with past medical history of Obesity, type 2 diabetes mellitus, renal cell carcinoma post right sided nephrectomy 22 years prior presented with recurrent back pain associated with nausea and vomiting. Physical exam was unremarkable. Liver function test (LFT), amylase, and lipase were all normal. Computed tomography (CT) scan and right upper quadrant ultrasound showed no evidence of acute cholecystitis. The patient was started on a course of Amoxicillin/clavulanate and discharged home with plans for outpatient surgical follow up for possible elective cholecystectomy in two weeks. Shorty after discharge, patient was readmitted with the same complaint. hepatobiliary iminodiacetic acid (HIDA) scan showed a gallbladder ejection fraction of 7% and hence the patient underwent emergent laparoscopic cholecystectomy. The gallbladder was reported to be grossly gangrenous. Gangrenous cholecystitis (GC) is a rare but serious complication of acute cholecystitis. Although there are multiple tools that are highly specific for the detection of acute cholecystitis, the accuracy of those tests for diagnosing GC remains uncertain. A high index of suspicion of cholecystitis should be exercised when dealing with elderly obese patients with history of diabetes and atypical symptoms. Careful history and physical examination are essential in making a diagnosis. Diagnostic testing may be misleading and patients with a high index of suspicion should be evaluated by an experienced surgeon and offered elective Laparoscopic cholecystectomy as clinically indicated.