NMS. Casos Clínicos

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Chapter 7 ♦ Pancreatic and Hepatic Disorders

Figure 7-6: This 2D projective MRCP shows multiple round filling defects within the common bile duct consistent with multiple stones (arrowhead). (From Shirkhoda A. Variants and Pitfalls in Body Imaging , 2nd ed. Wolters Kluwer Health; 2010, Fig. 11-16B.)

Q: What is the most likely diagnosis? A: The high fever may indicate acute cholecystitis or a complication of gallbladder disease such as cholangitis, empyema of the gallbladder, or a pericholecystic abscess.

You begin resuscitation with IV fluids and antibiotics.

Q: What studies would you perform to establish a diagnosis? A: An ultrasound examination would still be the first study. SAMPLE You perform an ultrasound and find that the gallbladder is distended with fluid that has internal echoes and gallstones. Q: What is the next step? A: This finding most likely represents an empyema of the gallbladder. This condition generally requires IV antibiotics and emergent exploration with cholecystectomy, depending on the prior health of the patient. When the patient’s general health is poor, percutaneous chole- cystostomy to drain the gallbladder is an option with a lower operative risk (Fig. 7-7). Q: How would the proposed management change if the ultrasound study showed previous removal of the gallbladder, a dilated CBD, and air in the biliary system? A: These findings suggest a serious complication such as suppurative cholangitis from a retained CBD stone , which results when bacterial infection occurs with bile duct obstruction.