Recommended Citation
Stevenson JR, Hunt C, Hunde M, Abdelmagid A. Discordant Imaging in Rapidly Progressive Acute Acalculous Cholecystitis: Gangrenous Perforation Within 48 Hours. Poster presented at: American College of Gastroenterology (ACG) 2026 Annual Scientific Meeting; October 11, 2026; Nashville, TN. Poster P0211.
Presentation Notes
Poster presented at: American College of Gastroenterology (ACG) 2026 Annual Scientific Meeting; October 11, 2026; Nashville, TN. Poster P0211.
Abstract
Introduction: Acute acalculous cholecystitis (AAC) accounts for 5-10% of cholecystitis cases and carries higher mortality than calculous disease, particularly in debilitated patients. Diagnosis is challenging because findings are subtle and cross-sectional imaging is often nonspecific. We report a case of rapidly progressive AAC in which CT and right upper quadrant (RUQ) ultrasound underestimated disease severity, with hepatobiliary iminodiacetic acid (HIDA) scintigraphy establishing the diagnosis. Case Description: A 64-year-old nursing home resident with dementia, prior strokes, and type 2 diabetes presented with one day of diffuse abdominal pain, nausea, and vomiting. She was afebrile, heart rate 106, white blood cell (WBC) count 13.2, lactate 2.5, with normal liver chemistries and negative Murphy sign. CT abdomen showed a fluid-distended gallbladder without fat stranding. RUQ ultrasound demonstrated wall thickening to 4.34 mm and sludge without cholelithiasis, hyperemia, or sonographic Murphy sign, and was reported as nonspecific. Empiric piperacillin-tazobactam was started. By day two, WBC rose to 17.7 with worsening encephalopathy. HIDA showed nonfilling of the gallbladder despite morphine augmentation. At urgent surgery, the gallbladder was obscured by an omental drape; takedown revealed a walled-off bile collection from a full-thickness necrotic perforation at the dome. Cement-like adhesions at the gallbladder neck precluded safe dissection, prompting laparoscopic subtotal cholecystectomy with a 1-2 cm retained cuff and drain placement. Pathology confirmed acute gangrenous cholecystitis with transmural necrosis. The postoperative course was complicated by septic shock requiring intensive care, acute kidney injury, anemia, and a new multifocal right middle cerebral artery infarct identified on MRI obtained for persistent encephalopathy. She survived to discharge. Discussion: First-line imaging can substantially underestimate AAC severity in elderly, encephalopathic patients in whom history and Murphy sign are unreliable. Sonographic features overlap with sepsis-related gallbladder edema, and disease may progress to gangrene and perforation within 48 hours. HIDA retains the highest sensitivity for AAC and should be pursued early when suspicion exceeds ultrasound or CT findings. When inflammation obscures the critical view of safety, subtotal cholecystectomy is an accepted damage-control alternative, though it carries risks of bile leak and remnant infection. AI use disclosure: Generative AI tools assisted with literature review and language editing; no patient-identifiable information was entered, and authors verified content. A B Figure 1. Diagnostic imaging. (A) Right upper quadrant ultrasound demonstrating mild gallbladder wall thickening (4.34 mm) and intraluminal sludge, without cholelithiasis, wall hyperemia, or sonographic Murphy sign — interpreted as nonspecific. (B) Hepatobiliary iminodiacetic acid scintigraphy showing hepatic uptake and bowel filling with non-visualization of the gallbladder despite morphine augmentation, diagnostic of acute cholecystitis. Figure 2. Intraoperative laparoscopic view demonstrating the gangrenous gallbladder with full-thickness necrosis and walled-off perforation at the dome, obscured by an omental drape on initial inspection.
Type
Poster
Affiliations
Aurora Health Care