Hemorrhagic cholecystitis: ultrasound and CT imaging findings—a retrospective case review series

Abstract

Gallbladder pathology is diverse, and imaging tests are essential tools for its diagnosis. Acute cholecystitis has multiple manifestations or complications, one of which is hemorrhagic cholecystitis (HC). In the current literature, this pathology has been described only in the spectrum of acute cholecystitis complications, case reports, or series with a maximum of 2 to 3 cases. After a retrospective review, we present 11 cases of hemorrhagic cholecystitis and discuss its various causes, clinical presentations, and findings on ultrasound (US) and computed tomography (CT), considering dual-energy CT and magnetic resonance imaging (MRI). A retrospective review of 6 years (2012-2018) of hemorrhagic cholecystitis cases diagnosed at our hospital was performed. A search engine of medical terms was used and the database of radiological cases in the emergency department of the hospital. After a careful review by two emergency and one abdominal radiologists, 11 patients were identified as hemorrhagic cholecystitis cases according to their clinical, radiological, and surgical records and confirmed with pathology reports. Both lithiasis and anticoagulation/antiplatelet therapy were the most common etiologies found (9 patients, 82%). The clinical presentation may be misleading, simulating a usual cholecystitis episode with abdominal pain, nausea, and vomiting, or manifesting with signs of bile duct obstruction, hematemesis, or anemia that may compromise the patient hemodynamically and become fatal. US is useful, but CT is the most complete test for evaluating hemorrhagic cholecystitis and was performed in all the patients. The common findings were inflammatory changes in all patients (100%), hemobilia in 10 patients (91%), hemoperitoneum in 6 patients (55%), intestinal bleeding in 3 patients (27%), and occasionally perihepatic hematomas or signs of active bleeding. Although a rare entity, hemorrhagic cholecystitis may be present, and management can be delayed if the appropriate imaging modality is not used for diagnosis.