Echogenic Lesions Research Articles

Endometrial Microcalcification in a 31-Year-Old Woman: A Case Report

Endometrial microcalcifications are an uncommon event, though they may be a cause of amenorrhoea and infertility. It is often detected incidentally as echogenic lesions on ultrasonography and in endometrial samples sent for histopathological examination. A 31-year-old Para 0+3 presented with amenorrhoea and a “curettage sample” obtained from an evacuation performed for a missed abortion at ten weeks gestation. She brought the tissue obtained during the endometrial curettage, which was performed at a private hospital for histopathological examination and follow-up at the Gynaecology Clinic. A provisional diagnosis of atrophic endometrium was made following a pelvic ultrasound scan, while histopathological examination revealed placenta tissue with microcalcifications. The patient was subsequently placed on combined oral contraceptives for three cycles, having ruled out possible contraindications. She had regular per vaginam bleeding for three consecutive cycles. She resumed spontaneous menses and eventually achieved pregnancy. Although endometrial microcalcification is rare, it is a potential cause of secondary amenorrhea and infertility in women of reproductive age group.

Placental lakes vs lacunae: spot the differences.

Sonographic sonolucencies are anechoic areas surrounded by tissue of normal echogenicity, commonly found in the placental parenchyma during the second and third trimesters of pregnancy. The ultrasound appearance of lakes and lacunae derives from the low echogenicity of villous-free areas within the placental parenchyma, filled with maternal blood of varying velocities. In normal placentation, lakes usually start appearing as soon as maternal blood begins to flow freely within the intervillous space at the end of the first trimester, whereas, in accreta placentation, lacunae develop progressively during the second trimester. Larger lakes are found mainly in areas of lower villous density under the fetal plate or in the marginal areas, but can also be found in the center of a lobule above the entry of a spiral artery. Lakes of variable size, position and shape are of no clinical significance, except if they transform into echogenic cystic lesions, which have been associated with poor fetal growth and placental malperfusion. Lacunae are formed by the distortion of one or more placental lobules developing inside a uterine scar, resulting from high-volume, high-velocity flows from the radial/arcuate arteries, and are associated with a high probability of placenta accreta spectrum at birth. They often present with ultrasound signs of uterine remodeling following scarring. Lakes and lacunae can coexist within the same placenta and both will change in size and shape as pregnancy advances. Better understanding of the etiopathology of placental sonolucent spaces and associated morphological changes is necessary to identify patients at risk of subsequent complications during pregnancy and/or at delivery. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Abstract 16833: Native Pulmonary Valve Infective Endocarditis in the Absence of Typical Risk Factors

Introduction: Isolated Pulmonary valve endocarditis (PVE) is a rare subset of right sided endocarditis associated with high mortality. We describe a case of PVE without typical risk factors. Case: A 53-year-old male with a history of controlled type 2 diabetes, coronary artery disease and recent minor trauma to the foot presented with 1 week of intermittent fevers, night sweats, and decreased appetite. Vital signs revealed a temperature of 103°F. Exam was significant for a grade II diastolic murmur best heard on the left sternal border and a healed wound on the left 5th metatarsal. Blood cultures taken grew Methicillin-Resistant Staphylococcus Aureus. A trans-thoracic echocardiogram revealed an echo dense material on the pulmonary valve measuring 1.0 x 0.3 cm. Differential diagnosis included endocarditis, pulmonary fibroelastoma, thrombus, or a cardiac tumor. A trans-esophageal echocardiogram later obtained revealed an echogenic lesion on the pulmonic valve measuring 2.1 x 1.2 cm with severe pulmonic insufficiency. An echodensity adherent to the right ventricular wall was also visualized. Tricuspid valve appeared normal. Due to persistent bacteremia despite appropriate antimicrobial coverage and significant valvular insufficiency, a decision was made to proceed with cardiac surgery. Patient received debridement to both pulmonary valve and right ventricular vegetations and underwent pulmonary valve replacement. Intraoperative pathology was consistent with endocarditis. The nidus for infection was attributed to the patient’s recent traumatic wound. The patient was discharged home with 6 weeks of daptomycin therapy. Conclusion: Right sided endocarditis involving the pulmonic valve is rare but can occur in individuals without an obvious predisposing cardiac structural abnormality. In our case, the patient developed severe valvular insufficiency therefore was successfully treated with surgical intervention and a prolonged course of antibiotics.

Fibrous hamartoma of infancy: imaging findings.

Fibrous hamartoma of infancy is a benign tumor that typically arises within the first 2years of life in the subcutaneous and lower dermal layers. Diagnosis can be challenging as it is a rare tumor, and the imaging appearance is not well known. To describe the imaging features in 4 cases of fibrous hamartoma of infancy focusing on ultrasound (US) and magnetic resonance (MR) findings. In this retrospective IRB-approved study, informed consent was waived. We searched patient charts for histopathology-confirmed fibrous hamartoma of infancy diagnosis between November 2013 and November 2022. We found four cases, three boys and one girl, and the mean age was 1.4years (5months-3years). The lesions were located in the axilla, posterior elbow, posterior neck, and lower back. All four patients underwent ultrasound evaluation of the lesion, and two patients also underwent MRI evaluation. The imaging findings were reviewed by consensus by two pediatric radiologists. US imaging revealed subcutaneous lesions with variably defined hyperechoic regions and intervening hypoechoic bands resulting in a linear "serpentine" pattern or a "multiple semicircle" pattern. MR imaging evidenced heterogeneous soft tissue masses, localized in the subcutaneous fat, and showed hyperintense fat interspersed with hypointense septations on both T1- and T2-weighted images. Fibrous hamartoma of infancy has a suggestive appearance on US with heterogeneous, echogenic subcutaneous lesions with intervening hypoechoic portions, in parallel or circumferential arrangement that can be seen as a serpentine or semicircular pattern. On MRI, interspersed macroscopic fatty components show high signal intensity on T1- and T2-weighted images and reduced signal on fat-suppressed inversion recovery images, with irregular peripheral enhancement.

Subcentimeter Echogenic Renal Lesions: Counterpoint-Subcentimeter Echogenic Renal Lesions Should be Followed With Ultrasound.

This article does not include an abstract. Please see the accompanying Point by Satheesh Krishna.

Bright Is Not Always Better: A Pictorial Review of Hyperechoic Malignant Breast Masses.

Hyperechogenic breast lesions are a relatively rare finding at breast ultrasonography and are traditionally thought to be benign. However, hyperechogenicity on the ultrasound alone does not provide enough evidence to rule out malignancy completely. We herein reported a short series of nine cases of echogenic malignant breast lesions, which include invasive ductal carcinoma, ductal carcinoma in situ, invasive lobular carcinoma, angiosarcoma, lymphoma, and metastasis to the breast. Echogenic breast lesions should be carefully evaluated and properly categorized based on any other suspicious sonographic characteristics and must be correlated with mammographic findings and clinical history to lower the threshold for biopsy and avoid delay in diagnosis. Hyperechogenicity should not be considered as a characteristically benign feature and should not supersede the less specifically benign features of the same lesion on the other examination.

Papillary Thyroid Carcinoma Arising in Thyroglossal Duct Cyst and Locally Infiltrated to Hyoid Bone: Issue of Individualized Management

Thyroglossal duct cyst (TGDC) is the most common developmental anomaly of the thyroid gland, while TGDC carcinoma with local infiltration to the hyoid bone is extremely rare. The reported case of papillary thyroid carcinoma (PTC) was diagnosed in TGDC along with local infiltration to the hyoid bone and needed individualized management. A 70-year-old male patient presented with a history of PTC arising in TGDC and locally infiltrated to the hyoid bone followed by total thyroidectomy and radical sistrunk operations and was referred to National Institute of Nuclear Medicine and Allied Sciences (NINMAS) for radioactive iodine therapy (RAIT). His post-operative ultrasound of the neck revealed an irregular shaped, fungating, grossly non-homogenous mixed echogenic mass lesion invading the hyoid bone, measuring about 25 X 28 mm. Radioactive iodine(131I) of 150 mCi was administered because the residual hyoid bone mass was inoperable and he was on thyroxine suppression therapy. The post-therapy 131I scan (RxWBS) showed two intense foci of radiotracer concentration (RTC) in the upper area (above the thyroid bed) and an intense focal RTC in the fundal region of the stomach. The activity in the stomach region was evaluated by ultrasound imaging, which revealed a soft tissue mass or thickening of the mid-region of the posterior wall of the stomach (3.3 cm X 1.6 cm). A CT scan of the chest was also performed to rule out metastasis, and it revealed multiple nodular lesions in both lung fields (most likely secondary) as well as tiny subcentric lymphnodes in the lower pre- and right paratracheal regions after nearly one month of RAIT when the patient was stable for examination. EBRT is still under consideration as adjuvant therapy. Tyrosine kinase inhibitors (TKI) may be considered in cases of refractoriness to radioiodine and disease progression. Bangladesh J. Nuclear Med. 26(1): 67-70, 2023

Isolated Tuberculosis of the Thyroid Gland: A Common Disease at an Uncommon Location

Abstract Tuberculosis (TB) of the thyroid gland is extremely rare, even in areas where the prevalence of TB is very high. Only a few such cases have been reported in the literature. The clinical course may resemble toxic goiter or acute thyroiditis. We report the case of a 23-year-old male who presented with painless swelling of the thyroid gland associated with mild fever and weight loss. On ultrasound neck, a large echogenic solid lesion was seen. Fine-needle aspiration cytology was suggestive of colloid goiter, but histopathology study suggested TB of the thyroid gland along with colloid goiter. We report this case to emphasize that TB of the thyroid gland, although rare, should be kept in the differential diagnosis of thyroid nodules, especially in countries such as India which are endemic for TB.

ODP278 A rare case of Ectopic ACTH secretion associated with Primary Gastric Choriocarcinoma

Abstract Background Ectopic ACTH production contributes to 10-15% of cases of Cushing's syndrome. Most cases are caused by neuroendocrine tumors of the lung, pancreas, or thymus. Other rare tumors causing ectopic ACTH secretion include esophageal tumor, gastric carcinoid tumor and squamous cell carcinoma of the larynx (1). We present a rare case of ectopic ACTH production causing Cushing syndrome due to primary gastric choriocarcinoma. Case Presentation A 27-year-old lady, not known to have any chronic illnesses, presented with two days history of epigastric pain. The patient also reported facial puffiness, leg swelling, generalized weakness and oligomenorrhea for the last four months. There was no history of easy bruisability or weight. She was not taking any medications. The patient did not smoke or use alcohol. Physical examination revealed conjunctival pallor, facial acne, wide striae on her thighs and hepatomegaly. The rest of the examination was normal. Lab tests showed microcytic anemia with hemoglobin of 7 gm/dl (12-15 gm/dl), hypokalemia (2.5 mmol/L; normal 3.5-5.3 mmol/L), AST 38 U/L (0-40 U/L) and ALT 45 U/L (0-41 U/L). β HCG was 1,506 mIU/mL (0 -5 mIU/ml). An abdominal ultrasound showed hepatomegaly with multiple echogenic solid mass lesions suspicious of metastatic origin. A CT abdomen showed a solid lesion in the fundal region of the stomach with multiple liver metastases and moderate ascites. An esophagogastroduodenoscopy showed fungating mass originating from the stomach fundus. Biopsy of the gastric mass revealed primary gastric adenocarcinoma, which was positive forCK 7, CK 19, beta hCG, CDX2 and CEA, consistent with the diagnosis of primary gastric choriocarcinoma. Due to widespread metastasis, the patient was started on palliative chemotherapy with dexamethasone 2 mg injection once daily along with capecitabine, cisplatin and pembrolizumab. In view of persistent hypokalemia and physical examination findings, a workup for Cushing's syndrome was performed. Early-morning serum cortisol was 1054 nmol/L (138–689 nmol/L), and plasma ACTH was 174 pg/ml (7.2-63.3 pg/ml) despite the patient being on intravenous 2 mg dexamethasone once daily for more than ten days. An MRI of the brain showed a normal pituitary gland. Based on these findings, the patient was diagnosed with Cushing's syndrome due to ectopic ACTH secretion. Unfortunately, her hospital course was complicated by massive upper gastrointestinal bleeding from the tumor, leading to her demise. Conclusion Gastric choriocarcinoma is a rare tumor associated with ectopic ACTH secretion leading to Cushing's syndrome. Reference: Imura H, Matsukura S, Yamamoto H, Hirata Y, Nakai Y. Studies on ectopic ACTH-producing tumors. II. Clinical and biochemical features of 30 cases. Cancer. 1975 May;35(5): 1430-7 Presentation: No date and time listed

Penetrating Ocular Injury Management in Intraocular Foreign Body (IOFB) and Traumatic Cataract

Highlight: The management of penetrating ocular injury with IOFB and traumatic cataracts needs a thorough examination of the mechanism of injury, location, size, and composition of IOFB. Endophthalmitis, retinal detachment, and development of PVR are potentially vision-threatment. Abstract: Most IOFB are metallic and found in males of productive age as a consequence of work-related accidents. A 45-year-old man complained of sudden blurred vision in the left eye (3/60 pinhole 5/12) after getting hit by a foreign body when cutting grass with a lawn mower. Anterior segment examination revealed a 10 mm long, one-plane, straight, full thickness, already sutured inferonasal corneal laceration, inferonasal traumatic iridectomy size 3x7 mm, and opaque lens. Head CT-scan revealed opacity with metallic density intraocularly. Ultrasonography revealed an echogenic lesion, particle-shaped with 100% RCS complex density, located at the inferonasal of the vitreous cavity. Focal laser photocoagulation was performed preoperatively because there was a tear at the superonasal of the retina. The patient underwent cataract extraction, intraocular lens implantation, vitrectomy, and IOFB extraction in a one-step procedure. IOFB was found at the inferonasal side of a vitreous cavity with size 3 x 1 mm, metallic, and not attached to the retina. Silicon oil tamponade was used as a precaution because there were retinal tears. Postoperatively, the left eye's visualacuity was 5/20. After 6 months, the silicon oil was evacuated and the visual acuity became 5/8.5.

Assessment Challenges of Echogenic Breast Lesions

An echogenic breast mass is defined as a hyperechoic lesion compared with subcutaneous adipose tissue at ultrasonography (US). This is in accordance with the US lexicon of the Breast Imaging Reporting and Data System (BI-RADS) of the American College of Radiology. Although most echogenic solid breast masses identified on ultrasound imaging are benign, hyper-echogenicity alone does not exclude malignancy. Approximately 0.5% of malignant breast lesions appear echogenic. Therefore, upon finding a solid, echogenic mass on ultrasound, it is important to correlate with the mammographic findings to decide on the necessity of a biopsy. The case reports in this paper confirm that similar-looking masses on ultrasound imaging can have a different diagnosis.

Young Man with Epigastric Pain

A 29-year–old otherwise healthy man sustained epigastric and periumbilical pain for 3 days before his emergency department visit. The pain was intermittent, dull, without radiation, and not associated with posture change or food ingestion. On arrival, his vital signs were stable. Physical examination showed epigastric tenderness without rebounding pain. A bedside point-of-care ultrasound revealed an intraluminal echogenic lesion that completely obstructed the superior mesenteric vein (Figure 1).

Ultrasound Assessment of Echogenic Breast Lesions. Is It Enough For Diagnosis?

Ultrasound Assessment of Echogenic Breast Lesions. Is It Enough For Diagnosis?

A proteomic atlas of atherosclerosis: regional proteomic signatures for plaque inflammation and calcification

Abstract Funding Acknowledgements Type of funding sources: Foundation. Main funding source(s): This study was mainly supported from the British Heart Foundation (BHF) supporting Prof. Manuel Mayr as a Chair Holder (CH/16/3/32406) with BHF programme grant support (RG/16/14/32397) and Dr. Theofilatos with BHF programm grant support (G/20/10387). Background Using proteomics, we strove to reveal novel molecular subtypes of human atherosclerotic lesions, study their associations with histology and imaging and relate them to long-term cardiovascular outcomes. Methods 219 samples were obtained from 120 patients undergoing carotid endarterectomy. Sequential protein extraction was combined with multiplexed, discovery proteomics. Parallel reaction monitoring for 135 proteins was deployed for targeted validation. A combination of statistical, bioinformatics and machine learning methods was used to perform differential expression, network, pathway enrichment analysis and train and evaluate prognostic models. Results Our extensive proteomics analysis from the core and periphery of plaques doubled the coverage of the plaque proteome compared to the largest proteomics study on atherosclerosis thus far. Plaque inflammation and calcification signatures were inversely correlated and validated with targeted proteomics. The inflammation signature was enriched with neutrophil-derived proteins, including calprotectin (S100A8/9) and myeloperoxidase. The calcification signature contained fetuin-A, osteopontin, and gamma-carboxylated proteins. Sex differences in the proteome of atherosclerosis were explained by a higher proportion of calcified plaques in women. Single-cell RNA sequencing data attributed the inflammation signature predominantly to neutrophils and macrophages and the calcification signature to smooth muscle cells, except for certain plasma proteins that were not expressed but retained in the plaque, i.e., fetuin-A. Echogenic lesions reflect the collagen content and calcification of plaque but carotid Duplex ultrasound fails to capture the extent of inflammatory protein changes in symptomatic plaques. Applying dimensionality reduction and machine learning on the proteomics data defined 4 distinct plaque phenotypes and revealed key protein signatures linked to smooth muscle cell content, plaque calcification and structural extracellular matrix, which improved the 9-year prognostic AUC by 25% compared to ultrasound and histology. A biosignature of four proteins (CNN1, PROC, SERPH, and CSPG2) independently predicted the progression of atherosclerosis and cardiovascular mortality with an AUC of 75% Conclusion We combined discovery and targeted proteomics with network reconstruction and clustering techniques to provide molecular insights into protein changes in atherosclerotic plaques. The application of proteomics and machine learning techniques revealed distinct clusters of plaques that inform on disease progression and future adverse cardiovascular events.

Retained appendicolith: Some things work themselves out

Management of perforated appendicitis has been debated for decades, remaining controversial today. Data is scarce regarding the approach to retained appendicolith after appendectomy. A 14-year-old girl presented with perforated appendicitis and an extraluminal appendicolith. IV antibiotics were initiated and drain placed until resolution of intraabdominal abscess. The drain was removed, and she was discharged on oral antibiotics. Ten days later she developed pain and purulent drainage from the drain site and was found to have a reaccumulated collection, so antibiotics were restarted, and she improved. Weeks later interval laparoscopic appendectomy ensued; the appendix was inflamed, and purulent fluid was noted in the pelvis. She initially recovered until multiple abscess recurrences, first temporized by percutaneous drainage, and subsequently by 6 weeks of antibiotics. Finally, workup of progressive right hip pain and swelling revealed a subcutaneous collection containing a shadowing echogenic lesion, consistent with the appendicolith from initial CT. Incision and drainage yielded pus and a 12 mm brown calcified mass; packing was placed. She was discharged on amoxicillin and continued wound care. Pathologic evaluation described a mass of calcified degenerated vegetable matter and food particles consistent with an appendicolith. Two years later she is without recurrent symptoms.

The value of transthoracic echocardiography in the detection of extra-cardiac lesions

ObjectiveTransthoracic echocardiography (TTE) is generally recognized as the top choice for detecting myocardial and cardiac cavity lesions. Sonographers mostly focus on myocardium, cardiac cavity and cardiac hemodynamics, whereas the abnormal extra-cardiac lesions are easily remain unrecognized. The aim of this study was to investigate the ultrasonic image features in abnormal extra-cardiac lesions and the value of TTE in the detection of extra-cardiac lesions.Methods49 cases of abnormal extra-cardiac lesion detected by TTE from January 2014 to December 2019 were collected, which were confirmed by surgical pathology. The two-dimensional ultrasonic characteristics and the relationships with the cardiac and great vessels were summarized on the basis of multi-view by TTE. All patients were also examined by computed tomography (CT).ResultsIn 49 patients with abnormal extra-cardiac lesions, 37 malignant cases and 12 benign cases were included. There were 41 cases (41/49, 86.67%) of mediastinal lesions and 8 cases (8/49, 16.33%) of lung lesions. The maximum diameter ranged from 3.2 cm to 13.66 cm, and the median diameter was about 7.4 cm, among which 29 cases (29/49, 59.18%) were larger than 5 cm. 4 cases (4/49, 8.16%) of cystic anechoic lesions were pericardial cyst. 2 cases (2/49, 4.08%) of cystic-solid echogenic lesions were teratoma. The remaining 43 cases (43/49, 87.76%) presented as solid hypoechoic or heterogeneous masses. 6 cases compressed the heart and 21 cases encroached on the heart and vessels. Diagnosis coincidence rates of TTE and CT were respectively 77.55% and 93.88%, with a statistical difference (p = 0.012).ConclusionAlthough the diagnostic coincidence rate of TTE is slightly lower than that of CT, TTE has certain diagnostic value for extra-cardiac lesions.

Antenatal diagnosis of congenital pulmonary airway malformation – two case report

BackgroundCongenital Pulmonary Airway Malformation (CPAM), is the most common Congenital Thoracic Malformation, accounting for 95% of congenital echogenic lung lesions detected antenatally on ultrasonography (USG).
 Antenatally diagnosed CPAM may regress or result in hydrops fetalis. Management options include expectant fetal follow-up, maternal administration of steroids and fetal surgery. We present two cases of antenatally diagnosed CPAM with both mothers consenting to and receiving antenatal steroids.
 Case 1
 A 31-year-old primigravida was noted with homogeneous highly hyperechoic right lung mass measuring 3.0 x 3.1 x 2.5cm at 24 weeks gestation on USG. The mass-to-thorax ratio (MTR) was 0.72, with no systemic feeding artery noted, stomach bubble was normally situated, there was no hydrops. An initial diagnosis of CPAM of the right lung was made. At 38 weeks’ gestation, USG showed mass was unmeasurable. Delivery was via CS at 39 weeks. Baby was well at birth and discharged home after 48 hours of monitoring, baby is 4 months old and growing well
 Case 2
 A 33-year-old G4P3AA was diagnosed with CPAM on USG at 22 weeks’ gestation. There was displacement of fetal heart to the right hemi-thorax. Colour Doppler did not show a systemic feeding arterial supply, or hydrops, and no associated structural anomaly. Serial USG for MTR at 28- and 32-weeks’ gestation showed increase of 0.72 and 0.86 respectively, with polyhydramnios. Further USG noted MTR of 0.57. Delivery was by emergency caesarean section (CS) for prolonged labour at term. Baby required admission due to hypoxia and respiratory distress on the first day of life, baby was discharged on day 14 post-delivery. Chest computed tomographic angiogram noted a feeding vessel to part of the right lung. Patient is 6 months old and has undergone a successful surgery.
 Conclusion
 Antenatal USG diagnosis and multidisciplinary approach to management in Congenital Thoracic Malformations is essential and improves antenatal and post-natal outcomes.

Etiology of Small Echogenic Renal Masses.

There has been controversy on how frequently small echogenic masses are angiomyolipomas (AMLs) versus renal cell carcinoma (RCC) and how best to manage these echogenic masses. We performed this study to determine the etiologies of echogenic renal masses and compare them with prior publications to reach possible management decisions. This is a retrospective chart review of all consecutive renal ultrasound examinations performed at our institution between January 2015 and December 2016, with an ultrasound report finding containing the wording "echogenic" and "mass." This yielded 6462 total examinations. A total of 107 echogenic lesions met inclusion and exclusion criteria with correlative computed tomography, pathology, or long-term (>5 years) follow-up ultrasound. These lesions were stratified into those that were ≤2cm and those that were >2cm. Almost all masses were benign, with the majority (79/107) being AMLs (73.8%); 64 of the 79 (81%) of the AMLs were in female patients. Two of the 107 masses were RCCs, and 1 mass was an oncocytic neoplasm. There were 77 of the masses that were ≤2cm and these masses were benign except for one lesion of an oncocytic neoplasm. There were 30 of the 107 masses >2cm, with 2 of the 30 (6.7%) being RCCs. Incidental echogenic renal masses are most commonly AMLs. However, some masses may be RCCs. In comparing our results with the prior literature, we feel that small echogenic renal masses ≤1cm usually require no further evaluation, while masses greater than that size require other imaging.

Sonographic and Mammographic Features of Different Echogenic Breast Lesions: A Pictorial Essay

Sonographic and Mammographic Features of Different Echogenic Breast Lesions: A Pictorial Essay

An Unusual Case of Haemobilia

Introduction: Haemobilia a rare cause of acute abdomen presents with Quincke’s triad: right upper quadrant pain, jaundice and gastrointestinal bleeding. Hemorrhagic cholecystitis is a rare cause of haemobilia. Case Presentation: A 30 year-old gentleman presented with right upper quadrant pain for 5 days, associated with fever, vomiting and jaundice. Patient was pale and icteric and right hypochondrium was tender with palpable gallbladder. His hemoglobin was 7.7 gm/dl with deranged liver function test (LFT). Abdominal ultrasonography demonstrated edematous and contracted gallbladder wall with echogenic lesion within the lumen. Computed tomography (CT) scan of abdomen revealed a mildly distended gallbladder, bilateral intrahepatic biliary radical dilatation and dilated common bile duct (CBD) with hyperdense sludge in the gallbladder and CBD. Patient developed per rectal bleeding on the fourth day of admission. Upper GI endoscopy showed blood pooling from ampulla of Vater. Abnormal blushing of gallbladder wall with abnormal enhancement at neck of gallbladder arising from cystic artery, was noted on angiography, suggestive of hemorrhagic cholecystitis. During surgery thickened gallbladder wall, engorged cystic artery and blood mixed with clot was seen in the gallbladder lumen. Cholecystectomy with choledochoscopy was performed. Choledochoscopy demonstrated normal extrahepatic biliary channel. Post-operative period was uneventful, blood hemoglobin level was static and LFT improved. Patient was discharged on fourth post-operative day. Conclusions: Haemobilia can be fatal condition hence mandates urgent diagnosis and treatment. Hemorrhagic cholecystitis is not to be forgotten as a cause of haemobilia.