Emergency Radiology

https://doi.org/10.1007/s10140-021-01944-z

REVIEW ARTICLE

Complications of cholecystitis: a comprehensive contemporary

imaging review
Kiran Maddu1 · Sonia Phadke1 · Carrie Hoff1

Received: 24 February 2021 / Accepted: 10 May 2021

© American Society of Emergency Radiology 2021

Abstract
Acute cholecystitis is a common cause of right upper quadrant pain in patients presenting to the emergency department.
Ultrasound, computed tomography, HIDA scans, and magnetic resonance imaging are increasingly utilized to evaluate
suspected cases. The prognosis of acute cholecystitis is usually excellent with timely diagnosis and management. However,
complications associated with cholecystitis pose a considerable challenge to the clinician and radiologist. Complications of
acute cholecystitis may result from secondary bacterial infection or mural ischemia secondary to increased intramural pres-
sure. The recognized subtypes of complicated cholecystitis are hemorrhagic, gangrenous, and emphysematous cholecystitis,
as well as gallbladder perforation. Acute acalculous cholecystitis is a form of cholecystitis that occurs as a complication of
severe illness in the absence of gallstones or without gallstone-related inflammation. Complicated cholecystitis may cause
significant morbidity and mortality, and early diagnosis and recognition play a pivotal role in the management and early
surgical planning. As appropriate utilization of imaging resources plays an essential role in diagnosis and management,
the emergency radiologist should be aware of the spectrum of complications related to cholecystitis and the characteristic
imaging features. This article aims to offer a comprehensive contemporary review of clinical and cross-sectional imaging
findings of complications associated with cholecystitis. In conclusion, cross-sectional imaging is pivotal in identifying the
complications related to cholecystitis. Preoperative detection of this complicated cholecystitis can help the care providers
and operating surgeon to be prepared for a potentially more complicated procedure and course of recovery.

Keywords  Acute cholecystitis · Ultrasound · CT

Introduction hepatitis [1]. Therefore, almost all patients with suspected

cholecystitis require diagnostic imaging, including ultra-
Cholecystitis and its complications are pathologies com- sound (US), computed tomography (CT), or cholescintig-
monly encountered in the emergency department (ED). raphy (HIDA).
Clinical findings and laboratory test results are often insuf- Cystic duct obstruction due to gallstones accounts for 80
ficient to confirm or exclude the diagnosis of cholecystitis. to 95% of acute cholecystitis cases [2]. In classic acute cal-
In more than one-third of patients with clinical suspicion for culous cholecystitis, prolonged cystic duct obstruction from
cholecystitis, a different etiology for upper abdominal pain gallstones leads to gallbladder lumen distention and thick-
is diagnosed on imaging, including right lower lobe pneu- ening of the gallbladder wall due to submucosal edema. As
monia, pancreatitis, pyelonephritis, obstructive uropathy, or these findings progress, complicated cholecystitis may result
from increasing intraluminal pressure, mural inflammation,
* Kiran Maddu vascular compromise, hemorrhage, and gangrenous change,
[email protected] which may eventually lead to perforation. The recognized
Sonia Phadke subtypes of complicated cholecystitis are hemorrhagic, gan-
[email protected] grenous, and emphysematous cholecystitis, as well as gall-
Carrie Hoff bladder perforation [3].
[email protected] Acalculous cholecystitis accounts for the remaining 5
to 10% cases of cholecystitis [4]. Acalculous cholecysti-
1
Department of Radiology, Emory University Hospital, tis differs from calculous cholecystitis in that the patient
Atlanta, GA, USA

13
Vol.:(0123456789)
 Emergency Radiology

population is often critically ill before developing cholecys- Allowing for limitations, the diagnosis of acute chol-
titis. It is hypomotility-related gallbladder stasis, rather than ecystitis by US and CT is usually straightforward. The
an obstructing calculus, that results in increased intraluminal imaging findings suggesting cholecystitis on US and CT
pressure. Acalculous cholecystitis can be complicated by include gallstones, thickened and striated gallbladder wall,
mural inflammation, ischemia, and potential necrosis and distended gallbladder, pericholecystic fluid, fluid collections,
also result in perforation. Barie P.S et al. reported gallblad- and inflammatory fat changes. However, the detection of
der perforation in about 10% of acalculous cholecystitis cholecystitis complications on imaging is more challenging.
cases [5]. Wu et al. and Shapira-Rootman et al. concluded that the US
Overall, complicated cholecystitis is associated with could diagnose only a minimal portion (9% and 10%) of
higher morbidity and mortality [6]. Clinical presentation cases of cholecystitis complications [10, 11], but the sup-
may vary and is often masked by concomitant multiple plementary role of CT in the evaluation of complicated chol-
medical comorbidities, specifically in critically ill patients. ecystitis is well established, with sensitivity rates of 88–92%
Complicated cholecystitis necessitates timely management [8, 12]. Given some of the detection challenges, diagnosis of
to avoid catastrophic systemic complications, and radiologi- complicated cholecystitis should be considered a diagnosis
cal evaluation plays a critical role in proper management on a continuum from uncomplicated cholecystitis rather than
and patient prioritization in the ED setting. Clinically, it a discrete one.
is often very challenging to accurately diagnose patients MRI is not part of routine imaging for acute cholecystitis
with complicated cholecystitis because there is consider- in ED. However, MRI with MRCP is a useful complemen-
able overlap in the clinical presentation with other acute tary technique in cholecystitis evaluation, particularly in
abdominal disorders such as perforated duodenal ulcer, patients with inconclusive clinical findings and equivocal
liver abscess, pancreatitis, and other causes of septicemia imaging results on US and CT [13]. MRI has high sensitivity
[7]. Kim et al. designed a predictive model to complement for gallstone detection and assess for stones in the common
CT findings in diagnosing complicated cholecystitis [6]. The bile duct [2, 14]. MRI offers high sensitivity and specificity
potential risk of complicated cholecystitis increases with the in cholecystitis diagnosis and assists in preoperative assess-
following clinical variable as age > /65 years, male gender, ment of complications associated with cholecystitis [15].
BMI > /25, serum leukocyte count > /10,000/mm3, serum Algin et al. illustrated the utility of hepatocyte-specific MRI
neutrophil fraction > /80%, serum platelet count < 20,000/ contrast agent Gd-BOPTA in delineating GB wall perfora-
mm3, serum ALT level > /40 IU/L, and admission via the tion [16].
emergency department [6]. Together, clinical and imaging Hepatobiliary scintigraphy is an instrumental diagnos-
findings of complicated cholecystitis help prioritize patient tic tool in the ED setting when US and CT findings are
management. equivocal for acute cholecystitis. HIDA scanning, hepato-
biliary scintigraphy with technetium 99 m-labeled imino-
diacetic acid analog, has higher sensitivity and specificity
for the detection of acute cholecystitis than US [17]. How-
Overview of Imaging and key concepts ever, to our knowledge, there is no literature on the utili-
zation of HIDA scanning in the evaluation of cholecystitis
In patients presenting with right upper quadrant pain, US is complications.
the preferred imaging modality for initial evaluation. Nev- This review article will familiarize the radiologist with
ertheless, CT is used as an initial examination when patients the spectrum of imaging findings in severe or complicated
present with diffuse abdominal pain in a significant propor- cholecystitis (Table 1) and understand the challenges in early
tion of cases. Our experience shows that the utilization of detection of cholecystitis complications in the ED setting.
both CT and US is not uncommon. The significance of reviewing medical history extensively
Ultrasound is inexpensive, portable, and readily avail- as a criterion before interpreting complicated cholecystitis
able, and does not utilize ionizing radiation, making it most imaging findings is also emphasized in our discussion. The
convenient to begin the imaging evaluation of the patient. diagnosis of complicated cholecystitis is not straightfor-
Imaging with the US is ideally performed after at least 6 h ward; however, in the appropriate clinical context, critical
of fasting to achieve gallbladder distention, but this is omit- attention to specific imaging findings may indicate severe or
ted in the ED setting due to time constraints. US is more complicated cholecystitis and necessitate a more aggressive
sensitive than CT in detecting gallstones and substantially treatment approach or need for additional imaging workup,
more sensitive for the detection of acute biliary disease [8]. closer patient observation, monitoring, and even early sur-
Additionally, sonographers can assess for the presence of a gical intervention. The prognosis for most patients with
sonographic Murphy’s sign. However, US and CT’s specific- complicated cholecystitis is guarded, even after successful
ity are relatively similar at 95% and 93%, respectively [2, 9]. management [6].

13
 Table 1  Spectrum of imaging findings in severe or complicated cholecystitis

Hemorrhagic Gangrenous Emphysematous Acalculous Xanthogranulomatous

Emergency Radiology

Incidence 3.5% 22.7% 1–3% 10% Uncommon (22% presents as

acute cholecystitis)
Associated clinical conditions Uremia, coagulopathy, DM, Advanced age, male, ↑ WBC, Male 50–70y Very sick patients. DM, vas- Women in their sixth or seventh
anticoagulation (up to 45%), tachycardia DM, history of culitis, CHF, shock, cardiac decade; Gallstones are seen in
cystic artery aneurysm, GB EtOH abuse, dyspnea, and arrest, sepsis, malignancy, 80% of cases
neoplasm abnormal hematocrit BMT, ESRD, major trauma
and burns, post-op, pro-
longed ventilation, TPN
Imaging findings US: avascular echogenic US: Intraluminal membranes, US: Limited in assessment, US: May be easier given US: Hyperechoic wall thicken-
Note: US is usually the first intraluminal material distended GB Echogenic shadowing gas in pts critically ill, Findings ing, Intramural hypoechoic
line imaging modality for CT: Avascular hyperattenuat- CT: Intraluminal membranes, GB lumen or wall / efferves- similar to acute cholecystitis nodules, disruption of the
suspected biliary disease ing material, active extrava- hyperdense GB wall on cent GB without gallstones mucosal lining, perichol-
sation of contrast non-con CT, decreased wall CT: Gas in the GB lumen or CT: Similar to acute cholecys- ecystic fluid, GB stones and
MR: ↑ T1w signal intralumi- enhancement in distended wall (anaerobic infection), titis, cystic duct enhance- sludge, hypoechoic adjacent
nal or intramural material, GB, ± mural striations, pneumobilia, discontinuity ment increases sensitivity liver parenchyma
active extravasation of perforation of GB wall, abscess HIDA: May demonstrate GB CT: Hypodense intramural
contrast MR: Supplementary role. MR: Supplementary role only. non-visualization, high nodules (5 to 20 mm), hetero-
Similar to CT findings, GB Nondependent signal void sensitivity but specificity geneous mural enhancement,
distension, irregular wall from luminal or mural gas is low infiltration into the perichol-
thickening with areas of MRI: Limited role due to ecystic fat / adjacent liver
decreased mural enhance- critically ill patients MRI: XG ↑T2w signal, IP-OP
ment shows fat within the thick-
ened gallbladder wall, XGC
nodules ↓ signal intensity
on OP, diffusion restriction
XGC > neoplasm
Pathophysiology Untreated AC ♋♊transmural Severe form of complicated Thrombosis or occlu- Biliary stasis from hypomotil- Intraluminal pressure ↑ due
inflammation and mucosal cholecystitis with transmural sion of the cystic artery ity♋♊ ↑ bile viscosity and to obstruction, superfi-
infarction and necrosi♋♊ inflammation and ischemic ischemic♋♊ necrosis of the functional obstruction♋♊ cial mucosal ulceration of
vascular insult with bleeding necrosis of the GB wall GB wall and necrosis♋♊ ↑ intraluminal pressure, the wall/ rupture of RA
from small mural vessels Leads to sepsis, intraperi- infection by gas- forming ischemia + hypoperfusion sinuses♋♊ intramural
Also, after biopsy, trauma, toneal abscess, and fistula organisms extravasation of bile♋♊
cystic a. aneurysm rupture, formation inflammatory response
cancer (histiocytes ingest cholesterol
crystals)

AC acute cholecystitis; RA Rokitansky-Aschoff; GB gallbladder; DM diabetes mellitus; BMT bone marrow transplant; ESRD end-stage renal disease; XG xanthogranulomas; IP-OP in-phase and
opposed phase; TPN total parental nutrition

13
 Emergency Radiology

Hemorrhagic cholecystitis Additional evaluation with color Doppler sonography can be

used to ensure that the echogenic contents within the gall-
Hemorrhagic cholecystitis is an infrequent complication and bladder lumen are avascular (Fig. 1B), representing sludge
usually due to the progression of both acute calculous and or blood clot, whereas detection of color signal within the
acalculous cholecystitis. The reported incidence of hemor- luminal contents raises concern for mass lesion like gall-
rhagic cholecystitis is 3.5%[18]. This subtype of acute chol- bladder carcinoma [26]. The typical non-contrast CT find-
ecystitis is more likely to occur in patients with comorbidi- ings include hyperattenuating (usually more than 30HU)
ties like uremia, coagulopathy, diabetes, and in patients on bile in the gallbladder lumen and possible fluid–fluid level
anticoagulation [19–21]. In a 2019 review, anticoagulation (Fig. 1C and Fig. 2A) [27–29]. Hague et al. recommended
therapy accounted for 45% of cases of hemorrhagic chol- triple-phase CT when high attenuation gallbladder material
ecystitis [22]. Untreated cholecystitis in a specific popula- is identified in a patient with hemobilia or hemoperitoneum
tion results in transmural inflammation, leading to mucosal to assess for a cystic artery pseudoaneurysm [30]. Arterial
infarction, necrosis, and subsequent vascular insult with phase CT may also show active contrast extravasation from
resultant hemorrhage due to bleeding from small vessels in gallbladder mass indicative of active bleeding (Fig. 2B)
the wall. The resultant hemorrhage within the gallbladder is [24]. It is essential to avoid mistaking vicarious excretion of
distinct from other forms of gallbladder necrosis and other contrast into the biliary system or milk of calcium bile for
subtypes of complicated cholecystitis. Necrosis of the intra- actual hemorrhage. While MRI evaluation is not routinely
mural branches of the cystic artery can also be a rare cause warranted, hemorrhage in the gallbladder wall and the lumen
of gallbladder intramural or intraluminal hemorrhage. Hem- on MRI is seen as high signal intensity of methemoglobin
orrhage within the gallbladder lumen may also occur after on T1-weighted images [31].
trauma, liver biopsy, or aneurysms (usually of the cystic Treatment for hemorrhagic cholecystitis depends on clini-
artery) rupturing into the bile ducts. Primary gallbladder cal presentation and imaging findings. In severe hemorrhagic
cancer and metastatic cancer also may rarely cause hem- cholecystitis presenting with hypovolemic shock, emergent
orrhagic cholecystitis [23]. Some case reports have shown resuscitation is the first line of management. If active con-
that NSAIDs, particularly antiplatelet agents like aspirin, can trast extravasation is recognized on CT or CTA, transcath-
also induce hemorrhagic cholecystitis [23]. eter embolization with particles and coils can be considered
Most patients who develop hemorrhagic cholecystitis may [32]. Definitive treatment is usually open or laparoscopic
already be quite ill due to multiple associated comorbidities. cholecystectomy, though percutaneous cholecystostomy is
This condition’s presenting symptoms are non-specific and occasionally employed in severely ill patients.
can be mistaken for other conditions such as thoracic aortic
dissection. The underlying complex health issues make clini- Gangrenous cholecystitis
cal diagnosis even more challenging. Biliary colic, hemate-
mesis, jaundice, and melena are the classic constellation of Gangrenous cholecystitis is a severe form of complicated
findings in hemorrhagic cholecystitis; however, most often, cholecystitis with histological evidence of transmural
the clinical presentation is indistinguishable from uncompli- inflammation and ischemic necrosis of the gallbladder wall
cated acute cholecystitis [24]. Blood products may accumu- [33]. The incidence of gangrenous cholecystitis is as high as
late in the cystic duct, causing obstruction, and subsequent 22.7% of acute cholecystitis in some studies [34], suggesting
inflammatory changes resemble acute calculous obstructive it is a relatively common complication. Identified risk factors
cholecystitis. Hemorrhagic cholecystitis leads to hemobilia, for gangrenous cholecystitis include advanced age, male sex,
which may manifest as hematemesis or melena, not seen elevated white blood cell count, tachycardia, and diabetes
in uncomplicated acute cholecystitis. Rarely this form of [35]. Ganapathy et al. additionally found that the history of
complicated cholecystitis can also present with hemorrhagic alcohol abuse, dyspnea, and abnormal hematocrit are other
shock, which is associated with a high mortality rate and characteristics associated with gangrenous cholecystitis [34].
requires immediate surgical intervention [25]. Right upper quadrant pain is the most common clinical
Routine imaging and MRI may aid in the diagnose of symptom as in acute cholecystitis, but one study observed
hemorrhagic cholecystitis but still has limitations, empha- that clinical Murphy’s sign was detected in 100% of patients
sizing the importance of maintaining a high level of clinical with gangrenous cholecystitis and in only 63% of patients
suspicion. At ultrasound, highly echogenic debris (Fig. 1A) with acute cholecystitis [36]. Mean WBC count is consider-
within the distended gallbladder lumen is suggestive but not ably higher in gangrenous cholecystitis than acute uncom-
pathognomonic of acute hemorrhagic cholecystitis. Tume- plicated cholecystitis (13.2 vs. 10.2) [36].
factive sludge and echogenic pus from gallbladder empyema Gallbladder wall thickening is a frequent finding
can also have a similar appearance [8]. Echogenic shadow- on ultrasound, and striations in the gallbladder wall
ing calculi within the sludge is not uncommon (Fig. 1A). (Fig. 3A) are characteristic but not specific of gangrenous

13
Emergency Radiology

Fig. 1  Hemorrhagic cholecysti-
tis: 81-year-old female, known
hypertension with severe RUQ
pain. (A) US image shows
echogenic debris suggesting
tumefactive sludge or hemor-
rhage in distended gallbladder
(arrow) and gallstones in the
fundus casting acoustic shadow-
ing (arrowhead). (B) Doppler
interrogation reveals normal
flow in the gallbladder wall
(arrow) mitigating against wall
necrosis, and no color uptake
within the luminal contents
represents sludge or blood clot
rather than a mass lesion. (C)
Axial non-contrast CT image
of abdomen demonstrates
hyperdense layering fluid in the
gallbladder (arrow) suggest-
ing hemorrhage. (D) Coronal
CECT image shows heteroge-
neously dense fluid collection
in the gallbladder (arrow) and
gallstone in the fundus region
(arrowhead). Patient was treated
with CT-guided cholecystos-
tomy, and thick sanguinous fluid
was drained. Eventually patient
underwent cholecystectomy

cholecystitis [8]. Similar to uncomplicated cholecystitis, mucosa or strands of fibrinous exudate, is more charac-
intraluminal sludge and gallstones can be seen in gangre- teristic of gangrenous cholecystitis[8].
nous cholecystitis. However, the presence of intraluminal Hyperdense gallbladder wall (34 to 50 HU) on unen-
membranes (Fig. 3A), which represent either sloughed hanced CT can help diagnose gangrenous cholecystitis but

13
 Emergency Radiology

Fig. 2  Hemorrhagic cholecys-
titis secondary to adenocarci-
noma of GB. Non-contrast axial
CT image (A) shows fluid–fluid
level (arrow) with intrinsic
attenuation of dependent
fluid around 40 HU, indicat-
ing hemorrhage within the
gallbladder lumen. CTA arterial
phase image (B) shows contrast
extravasation (arrow) from an
enhancing mass lesion (arrow-
head) in the non-dependent
portion of the gallbladder

is not pathognomonic [36, 37]. Decreased wall enhancement

in a markedly distended gallbladder (> 4 cm) on contrast-
enhanced CT demonstrates moderate sensitivity and high
specificity for gangrenous cholecystitis (Fig. 3B) [36]. CT
findings of mural striations and intraluminal membranes in
the gallbladder are described in the literature; however, the
results are conflicting [7, 36, 38]. Bennett et al. reported that
the intraluminal membranes on CT are observed in both gan-
grenous cholecystitis and acute uncomplicated cholecystitis
with similar frequency, and the incidence of mural striations
is slightly higher in patients with gangrenous cholecystitis
[7]. Soyer et al. reported that mural striations on CT were
noted in up to 80% of their patients with acute cholecystitis
[38]. Ganapathi et al. suggested that gangrenous cholecysti-
tis is less likely when intraluminal membranes or mural stri-
ations are present in a gallbladder that is not well distended
[36]. Transient adjacent hepatic parenchymal enhancement
and pericholecystic fluid are also recognized findings on
contrast-enhanced CT, though these findings are less specific
and may be seen with gangrenous or non-gangrenous chol-
ecystitis [28]. Perforation is one of the common complica-
tions of gangrenous cholecystitis. Other reported gangrenous
cholecystitis complications include sepsis, intraperitoneal
abscess, and fistula formation [39]. CT and US have high
specificity for detecting gangrenous cholecystitis; however,
they have low sensitivity (29.3%) [7]. In authors’ experi-
ence, MR imaging can be instrumental when diagnosis with
CT, and US is inconclusive despite high clinical suspicion
of complicated cholecystitis (Fig.  4A). The asymmetric
thickening and irregularity of the gallbladder wall are well
demonstrated on axial fat-suppressed T2-weighted images,
Fig. 3  Gangrenous cholecystitis. 34-year-old male amyotrophic lateral scle- fat-suppressed T1-weighted images, and contrast enhanced
rosis; recurrent urinary tract infection presents with fever and sepsis. (A)
US image shows diffuse wall edema (arrow), wall striation, and echogenic
T1-weighted images (Fig. 4B, C, and D). Other recognized
intraluminal membranes (arrowhead). (B) Axial CECT image shows wall features of gangrenous cholecystitis such as ulceration,
edema (arrow) and irregularity of mucosal wall and complex hyperat- hemorrhage, necrosis, or microabscess (Fig. 4D) in the gall-
tenuating dependent wall (arrowhead). No pericholecystic fluid was noted. bladder wall are also best identified on MR imaging [31].
Pathological diagnosis confirmed acute gangrenous cholecystitis
Contrast-enhanced MR demonstrates inhomogeneous wall

13
Emergency Radiology

Fig. 4  Gangrenous cholecys-
titis (MRI). 59-year-old male
with right upper quadrant pain
and fever. (A) Axial CT image
shows gallstones and gallblad-
der wall thickening (arrow),
and no acute abnormality was
diagnosed. MRI was performed
in regard to severe symptoms.
(B) Axial fat-suppressed
T2-weighted image shows irreg-
ular gallbladder wall thickening
with increased signal intensity
(arrow). (C) Precontrast axial
fat-suppressed T1-weighted
image delineates irregular
wall thickening and mucosal
irregularity (arrow). (D) Post-
contrast axial fat-suppressed
T1-weighted image clearly
demonstrates the disruption of
mucosal layer (arrow head) and
additionally illustrates a tiny
fluid pocket in the gallbladder
wall representing abscess

enhancement and better delineation of mucosal disruption [41]. EC results from infection of the gallbladder wall by
(Fig. 4D) [40]. anaerobes like Clostridium sp., or other microorganisms
Although open cholecystectomy is more commonly used like Escherichia coli, Klebsiella sp., Proteus culgaris, and
to treat gangrenous cholecystitis than patients with acute Salmonella derby [42].
cholecystitis, laparoscopic cholecystectomy remains the The pathophysiology of EC is different from acute or
mainstay of treatment. The utilization of open cholecys- chronic cholecystitis. Acute or chronic cholecystitis is
tectomy was reported to be between 15 and 21% in one induced by obstruction of gallbladder neck or cystic duct
study [34], but it is unclear if the preoperative diagnosis of due to gallstones. In contrast, emphysematous cholecystitis
gangrenous cholecystitis influences the surgical approach. usually results from thrombosis or occlusion of the cystic
Severe pericholecystic inflammation, perforation, or con- artery leading to ischemic necrosis of the gallbladder wall
cerning preoperative physical examination findings can and subsequent gallbladder necrosis and secondary infec-
prompt open cholecystectomy. When adjusted for patient tion by gas-forming organisms. Compared to acute chol-
and operative characteristics, the differences in risk of mor- ecystitis, EC carries a higher risk of perforation, and the
tality between open and laparoscopic cholecystectomy was mortality rate is also considerably higher at 15% vs. 4%
not significant [34]. [42].
EC usually presents as right upper quadrant abdominal
Emphysematous cholecystitis pain, significantly accompanying clinical symptoms include
fever, nausea, and vomiting. EC poses a diagnostic dilemma
Emphysematous cholecystitis (EC) is an unusual and clinically when presenting symptoms are vague and indis-
life-threatening type of complicated cholecystitis with tinguishable from uncomplicated acute cholecystitis. Addi-
an incidence of 1 to 3% of acute cholecystitis cases. EC tionally, the symptoms may be very subtle in patients with
predominantly involves male patients aged 50 to 70 years diabetes mellitus and end-stage renal disease [43].

13
 Emergency Radiology

Identifying gas in the gallbladder lumen or wall and/or yield false-negative results, and a calcified wall or multiple
in the biliary tract is the key imaging feature in diagnosing stones may mimic gas shadows and result in false-positive
emphysematous cholecystitis. It is imperative to ensure the results [45]. CT is a more sensitive and specific imaging
patient did not undergo any recent diagnostic or therapeutic study to recognize gas within the gallbladder lumen or
biliary tract intervention as a cause of luminal or mural gas. wall (Fig. 5B)[45]. Ancillary CT findings suggestive of EC
Some authors classify EC into three different stages based include pneumobilia, irregularity or discontinuity of gall-
on the location of gas on conventional radiographs: stage 1, bladder wall, pericholecystic fluid, and abscess formation
intraluminal gas; stage 2, intramural gas; and stage 3, gas in the liver [28]. MR imaging plays only a supplementary
within the pericholecystic tissues [44]. Plain radiograph role in the evaluation of EC with gas in the gallbladder
workup is unusual in the evaluation of RUQ pain; how- wall or lumen appearing as signal voids [31]. Gallstones
ever, intraluminal or intramural gas (Fig. 5A and B) can are usually differentiated from intraluminal gas by loca-
be identified on CT topogram images. Ultrasound is often tion: gas is identified as numerous floating signal void in
the initial mode of evaluation, though diagnosing EC can the non-dependent portion of the gallbladder lumen and/
be challenging on ultrasound. The imaging findings differ or within the bile ducts, whereas gallstones are seen in the
depending on the amount of gas in the gallbladder wall or dependent portion. Susceptibility artifact at air-tissue inter-
lumen: a fair amount of intramural or intraluminal gas will face is better appreciated on fat-suppressed T1-weighted,
produce highly echogenic reflectors with low level poste- T2-weighted, and black blood T2-weighted spin-echo pla-
rior shadowing and reverberation artifact known as dirty nar images than heavily T2-weighted images [31].
shadowing (ring down artifact) (Fig. 5C) [45]. Intraluminal Treatment requires aggressive care in the ICU with anti-
gas can form multiple small non-shadowing echogenic foci biotics, and fluid resuscitation until cholecystectomy can
that are mobile with a changes in the patient’s position, also be performed. Percutaneous drainage (Fig. 5D) has also
known as effervescent gallbladder [46]. On US, pockets of been used in the acute setting as a bridge to cholecystec-
gas in the pericholecystic region may obscure detail and tomy with favorable outcomes [47].

Fig. 5  Emphysematous
cholecystitis. A 68-year-old
male presents to ED. CT scout
image (A) shows air in the
lumen(arrowhead) and wall
of the enlarged gallbladder
(arrows). Axial CECT of the
abdomen (B) shows gas in the
wall of the gallbladder(arrows)
and an air-fluid level in the
lumen (arrowhead). Ultrasound
image (C) of the same patient
shows echogenic reflectors in
the gallbladder wall (arrow)
with dirty acoustic shadowing
and ring down artifact (arrow-
head). The patient was treated
with CT-guided cholecysto-
stomy, and axial CECT (D)
shows percutaneous transhe-
patic cholecystostomy tube
(arrow) within the gallbladder

13
Emergency Radiology

Acalculous cholecystitis

Acute acalculous cholecystitis (AAC) is a form of acute

cholecystitis that occurs as a complication of severe ill-
ness in the absence of gallstones or without gallstone-
related inflammation. AAC occurs when biliary stasis
from hypomotility results in increased bile viscosity and
functional obstruction, causing increased intraluminal
pressure and leading to ischemic change combined with
hypoperfusion [48, 49]. Biliary stasis can lead to bacterial
colonization and progress to gallbladder infection. AAC
accounts for approximately 10% of cases of acute chol-
ecystitis cases; it is typically seen in very sick patients or
in the setting of severe injury with predisposing factors
including diabetes mellitus, vasculitis, congestive heart
failure, shock, cardiac arrest, sepsis, malignancy including
leukemia, bone marrow transplant, end-stage renal disease,
major trauma and burns, post-operative state, prolonged
ventilation, and TPN [49, 50].
Early imaging diagnosis is imperative, given its pro-
pensity for progression to gangrene and perforation. AAC
should be considered in all critically ill septic and/or jaun-
diced patients [49]. Gallbladder gangrene is reported in
more than 50%, and perforation can be seen in 10% or more
patients [5, 49].
Sonographic findings in acute acalculous cholecystitis
are similar to acute calculous cholecystitis. Major criteria
for diagnosis include gallbladder wall thickening > 3 mm
(Fig. 6A), striated gallbladder/wall edema, positive sono-
graphic Murphy’s sign, pericholecystic fluid, mucosal
sloughing, intramural gas; the minor criteria include gall- Fig. 6  Acalculous cholecystitis leads to gangrenous cholecysti-
bladder distention > 5 cm in transverse diameter and echo- tis. 21-year-old male, extensive abdominal surgery post-gunshot
genic bile/sludge (Figs. 6A and 7A) [49, 50]. Either two wound, presents with sudden abdominal pain and emesis. US image
(A) depicts grossly distended GB with echogenic sludge (*) but no
major criteria or one major and two minor criteria are
stones, and GB wall thickening and edema (arrow). Coronal CECT
needed for diagnosis. It is noteworthy to remember that image (B) demonstrates distended gallbladder with pericholecystic fat
sonographic Murphy sign may not be elicited and is unreli- stranding and fluid. Note the lack of clear enhancement of GB wall
able in a patient who is obtunded, unconscious, or sedated. near the fundus (arrow heads)
Additionally, in trauma or post-surgical patients, abdominal
bandages may limit the sonographic window [51].
CT criteria are similar to sonographic criteria, and either aid in diagnosis (Fig. 7D); however, the specificity to diag-
two major criteria or one major and two minor criteria must nose acalculous cholecystitis is low [51].
be met. Major CT diagnosis criteria includes gallbladder Diagnosing acalculous cholecystitis is challenging and
wall thickening > 3 mm, subserosal halo sign/intramural requires prompt clinical suspicion, a multidisciplinary
edema, pericholecystic infiltration of fat (Figs. 6B and 7B), approach, and multimodality imaging to make a timely
pericholecystic fluid, mucosal sloughing, and intramural diagnosis. Mirvis et al. demonstrated robust CT sensitivity
gas. Minor criteria include gallbladder distention > 5 cm in and specificity of 100% for diagnosing acalculous chole-
transverse diameter and high-attenuation bile/sludge [49, cystitis in post-trauma patients, with US having a 92% sen-
50]. In their study, Kim et al. found that six out of seven sitivity and 96% specificity in the same population [51].
acute acalculous patients show cystic duct enhancement, and While scintigraphy (Fig. 7D) demonstrated sensitivity of
the inclusion of cystic duct enhancement (Fig. 7C) in the 95%, specificity is low at 38% with 54% false positives
major findings can improve the CT diagnostic sensitivity of [51]. Low specificity is expected given overlap between
acalculous cholecystitis [52]. Scintigraphy with HIDA may known causes of false positives such as TPN, poor hepatic
demonstrate non-visualization of the gallbladder, which can function, and severe illness, and conditions common after

13
 Emergency Radiology

Acalculous cholecystitis is refractory to medical man-

agement alone and was historically treated with cholecys-
tectomy. Percutaneous cholecystostomy can be curative in
85–90% of patients, and delayed cholecystectomy may not
be needed [49, 50, 53]. Identifying complications like gan-
grene or perforation at the time of diagnosis plays a pivotal
role in management. Cholecystectomy is the choice of treat-
ment for complicated AAC, but patients with severe illness
or those unfit for general anesthesia can only be treated with
percutaneous cholecystostomy (PC) [54, 55]. Percutane-
ous cholecystostomy works both as a temporizing measure
before surgery and also as a standard treatment option. The
recurrence rate of AAC is low, and only a small propor-
tion of patients require cholecystectomy following percuta-
neous cholecystostomy [56]. Lumen-apposing metal stent
(LAMS) placement through the GI tract into the gallbladder
is a recent advancement and alternative management which
creates internal drainage [57]. Patients who will never be
surgical candidates and have a shorter life expectancy, who
do not have interventional radiology services to perform PC,
or who have significant ascites, have shown equivocal suc-
cess with endoscopic ultrasound-guided gallbladder drain-
age with metal stents. Under the guidance of ultrasound, a
deployment device punctures through the duodenal bulb or
gastric antrum to access the gallbladder to create a secure
conduit between gallbladder and GI tract [57]. LAMS place-
ment could obviate the need for percutaneous drainage of
the gallbladder.

Gallbladder perforation

Acute perforated cholecystitis is a severe subtype of gall-

bladder pathology with a reported mortality of 9.5% [58].
The incidence of gallbladder perforation is between 2 and
11% and is associated with a high risk of morbidity [3]. The
common predisposing factors are infections, malignancy,
trauma, drugs (e.g., corticosteroids), and systemic diseases
such as diabetes mellitus and heart diseases [59]. Hemor-
rhagic, gangrenous, and emphysematous cholecystitis may
all lead to perforation of the gallbladder. Jansen et al. found
advanced gallbladder inflammation with empyematous, and
Fig. 7  58-year-old-female with diffuse abdominal pain. (A) US image
shows distended gallbladder (*). (B) Axial CECT image shows dis- gangrenous cholecystitis was the leading cause for perfora-
tended gallbladder (*) with decreased wall enhancement and strand- tion in a significant of cases [60]. In acalculous cholecystitis,
ing (arrow) however no wall thickening or edema. (C) Coronal CECT perforation can occur in about 10% of cases attributed to
image shows enhancement of the cystic duct (arrow), cystic duct sign either ischemia, inflammation, or infection[49]. Very rarely,
most likely representing underlying acute cholecystitis. (D) HIDA
scan reveals normal excretion of contrast material into common bile gallbladder perforation can present as a complication of
duct and small bowel loops with no filling of gallbladder enteric fever[61].
Although acute cholecystitis is more common in women,
perforation secondary to EC is common in men [3, 62, 63].
acute trauma [51]. Given that many of these patients are Perforation is also correlated with older age and cardio-
critically ill, bedside sonography may be more advanta- vascular comorbidities [63]. It can lead to bile peritonitis,
geous as an initial imaging modality, although CT has the abscess formation, pneumonia, renal failure, and pancrea-
ability to assess extrahepatic pathology. titis [3]. When the cystic duct becomes obstructed due to

13
Emergency Radiology

gallstones, the gallbladder lumen distends leading to an in which a cholecystobiliary fistula forms between the gall-
ischemic change in the gallbladder wall, necrosis, and result- bladder and common bile duct or proximal bile ducts [66].
ant perforation. The fundus is the most frequent site of per- The most common clinical presentation is pain abdomen,
foration due to relatively lower vascular supply [3, 62, 64]. fever, and vomiting, and some patients may present with
Niemeier described three main types of gallbladder per- signs of peritonitis. The perforated gallbladder may also pre-
forations in 1934, including acute perforations into the peri- sent atypically, like abdominal wall abscess or liver abscess,
toneal cavity (type I), subacute perforations with walled-off perplexing the clinical presentation [67].
peri-cholecystic abscess (type II), and chronic perforations Discontinuity of the gallbladder wall and recognition of
with cholecystoenteric fistula formation (type III) [65]. The extraluminal gallstones are more reliable imaging findings to
majority of cases in the reported series is subacute/type II diagnose gallbladder perforation [68]. While US is often per-
[64, 65]. A rare fourth type has been described by Andersen formed as the initial imaging test, CT is more sensitive for

Fig. 8  Gallbladder perforation with leaking stones. Axial CECT

image (A) shows nearly complete lack of gallbladder wall enhance- Fig. 9  Suppurative cholecystitis (empyema gallbladder). Axial CECT
ment (short arrow) anteriorly and dependent calculus within the gall- image (A) shows gross distention of gallbladder with heterogeneously
bladder (arrowhead). Hyperdense gallstones (long arrows) are also dense contents (*) with no fluid–fluid levels and focal wall defect
seen within the perihepatic fluid. Coronal CECT image (B) shows (arrowhead). Coronal CECT image (B) shows mucosal hyperen-
intraluminal and extraluminal calcified gallstones (arrows) extending hancement and wall edema (arrow) and mildly tortuous cystic artery
into perihepatic region. Distended gallbladder with no obvious wall (arrowheads) which was friable during surgery. Hyperdense fluid
enhancement and probable wall defect in the fundal region (black collection in right lower quadrant and copious bloodstained purulent
arrowhead) are also appreciated fluid was noted during surgery (*)

13
 Emergency Radiology

complications, including perforation [64]. Sonographic find- Emergency laparotomy is indicated in acute perforation
ing specific for perforation is “sonographic hole sign,” first of the gallbladder, particularly those with findings of large
described by Chau et al., which can be seen along with per- hemoperitoneum. However, laparoscopic cholecystectomy
icholecystic fluid or collection [69, 70]. While some authors has become an acceptable choice even in most severe com-
reported sonographic identification of the wall defect in 70% of plications of cholecystitis, despite free intraperitoneal bleed-
patients, other studies failed to identify a defect in any confirmed ing [72].
cases [3, 70, 71]. Boruah et al. demonstrated that US was able
to identify all cases when the defect in the gallbladder wall was
greater than 10 mm but could not make the diagnosis in type II Mimics of complicated cholecystitis
cases and type III cases with defects less than 10 mm [64]. with chronic etiology
CT findings specific for perforation include a defect in the
gallbladder wall (Fig. 8A and B) and extraluminal position Xanthogranulomatous cholecystitis
of gallstones (Fig. 8B) [28]. Initially described sonographi-
cally as a “hole sign,” defects in the gallbladder wall are Xanthogranulomatous cholecystitis (XGC) is an uncom-
more commonly seen at CT imaging (Fig. 8B) [71]. The mon sequela of cholecystitis and is typically seen in
other described findings are pericholecystic fluid, associ- women in their sixth or seventh decade [2]. Gallstones
ated abscess (or fluid collection), gallbladder wall thicken- are seen in 80% of cases of XGC [73]. XGC is a chronic
ing, layering gallbladder wall, gallbladder wall bulging or inflammatory disease of the gallbladder, and both focal
defect, and omental/mesenteric stranding, and peritoneal and diffuse forms of gallbladder involvement are reported.
air (Fig. 9A and B) [3, 71]. CT is valuable in recognizing Lipid-laden macrophages accumulate in the gallbladder
the type of perforation, extent of intraperitoneal free fluid, wall and form grayish-yellow nodules or streaks [74]. It is
and identifying complications like free intraperitoneal air believed that when the intraluminal pressure increases due
(Fig. 10A, B and C), bile leak, abscess formation, and small to obstruction of gallbladder outflow, superficial mucosal
bowel obstruction [28]. ulceration of the wall, or rupture of Rokitansky-Aschoff

Fig. 10  Gallbladder perforation,
type I acute free perforation as a
complication of gangrenous and
hemorrhagic gallbladder. Axial
CT images (A) and (B) depict
non-enhancing gallbladder wall
(arrow heads) and hyperdense
intraluminal contents (*) repre-
senting blood products within
a grossly distended gallblad-
der. Also note heterogeneous
intraperitoneal free fluid and
pockets of air (arrow). Coronal
CT image (C) shows heteroge-
neously dense intraperitoneal
free fluid (arrow) in commu-
nication with gallbladder and
surrounding omental/mesenteric
stranding

13
Emergency Radiology

sinuses can lead to intramural extravasation of bile, occasionally the inflammatory process can extend to the
which results in an inflammatory response as histiocytes liver, colon, or surrounding soft tissues[74].
ingest chemically irritating cholesterol crystals [75, 76]. Pathophysiology of XGC helps in understanding the
Although XGC is a chronic form of cholecystitis, 22% of imaging findings. As mentioned earlier, the extravasa-
cases can present as acute cholecystitis[77]. Complica- tion of bile into the gallbladder wall and subsequent mural
tions are reported in 32% of cases and include perfora- inflammation causes diffuse GB wall thickening. On imag-
tion, abscess formation, and enterocutaneous fistulas, and ing, XGC may present as diffuse or focal gallbladder wall

Fig. 11  57-year-old-female (A).
US image shows diffuse hyper-
echoic gallbladder wall thicken-
ing (arrow). Note is made of
mucosal defect and perichole-
cystic fluid in the fundus of gall-
bladder (arrowhead). (B) Axial
CECT image shows thickened
gallbladder wall, intramural tiny
hypodense nodules, and severe
inflammatory striations in the
pericholecystic region (arrow).
(C) Coronal CT clearly depicts
the hypodense nodules in the
wall (arrow heads). (D) Coronal
CECT image more anteriorly
demonstrates enhancing fluid
filled collection adjacent to gall-
bladder wall suggesting abscess
formation (arrow) and spread of
inflammation to adjacent bowel

13
 Emergency Radiology

thickening, ranging from 3 to 25 mm, with or without dis- different treatment protocols that demonstrate significant
tinct wall margins [78]. On ultrasound, gallbladder wall levels of morbidity and mortality. Emergency radiolo-
thickening is hyperechoic (Fig.  11A) in comparison to gists should be aware of these imaging findings to provide
the liver, and Parra et al. noticed this finding in 100% of timely diagnosis, proper management, and expedite treat-
patients in their study [78]. On US, the other hallmark is the ment. Preoperative detection of this complicated cholecys-
identification of intramural hypoechoic nodules that repre- titis can help the care providers and operating surgeon to
sent foci of xanthogranulomatous inflammation or small be prepared for a potentially more complicated procedure
abscesses [79]. Additional recognized sonographic findings and course of recovery.
are disruption of the mucosal lining, pericholecystic fluid,
GB stones and sludge, and hypoechoic echogenicity of the
adjacent liver parenchyma [79, 80]. CT findings include Compliance with ethical standard 
hypodense intramural nodules (5 to 20 mm), heterogeneous
enhancement of the wall, and infiltration into the perichole- Conflict of interest  The authors declare that they have no conflict in-
terest.
cystic fat and adjacent liver parenchyma (Fig. 11B) [2, 81].
Goshima et al. describe five imaging findings to differenti- Disclosures  Unrelated grant funding from NHTSA/CIREN.
ate XGC from gallbladder wall carcinoma: (1) continuous
linear enhancement of the mucosa, (2) intramural hypo-
attenuated nodules (Fig. 11C), (3) diffuse thickening of
the gallbladder wall (seen in 91% of XGC), (4) the absence
References
of macroscopic hepatic invasion, and (5) the absence of 1. Joshi G, Crawford KA, Hanna TN, Herr KD, Dahiya N, Menias
intrahepatic biliary ductal dilatation [82]. Identifying at CO (2018) US of right upper quadrant pain in the emergency
least three out of five characteristic findings differentiates department: diagnosing beyond gallbladder and biliary disease.
XGC from gallbladder malignancy. Nearly 36% of patients Radiographics 38(3):766–793. https://​doi.​org/​10.​1148/​rg.​20181​
70149
with XGC may show lymphadenopathy [81]. Rupture of the 2. Ratanaprasatporn L, Uyeda JW, Wortman JR, Richardson I,
gallbladder serosal layer with the spread of inflammatory Sodickson AD (2018) Multimodality imaging, including dual-
response into adjacent anatomic spaces can lead to small energy ct, in the evaluation of gallbladder disease. Radiograph-
pericholecystic abscesses (Fig. 11D) and adhesions with ics 38(1):75–89. https://​doi.​org/​10.​1148/​rg.​20181​70076
3. Derici H, Kara C, Bozdag AD, Nazli O, Tansug T, Akca E
adjacent liver, duodenum, and colon (Fig. 11D). (2006) Diagnosis and treatment of gallbladder perforation.
On MRI, xanthogranulomas have increased signal World J Gastroenterol 12(48):7832–7836. https://​doi.​org/​10.​
intensity on T2-weighted images. In-phase and opposed- 3748/​wjg.​v12.​i48.​7832
phase chemical shift imaging of MRI helps identify fat 4. Gore RM, Thakrar KH, Newmark GM, Mehta UK, Berlin JW
(2010) Gallbladder imaging. Gastroenterol Clin North Am
within the thickened gallbladder wall in patients with XGC 39(2):265–287. https://​doi.​org/​10.​1016/j.​gtc.​2010.​02.​009
[83]. Nearly 77% of XGC nodules showed reduced sig- 5. Barie PS, Fischer E (1995) Acute acalculous cholecystitis. J Am
nal intensity on out of phase imaging. Diffusion-weighted Coll Surg 180(2):232–244
magnetic resonance imaging helps differentiate XGC from 6. Kim KH, Kim SJ, Lee SC, Lee SK (2017) Risk assessment
scales and predictors for simple versus severe cholecystitis
wall thickening due to gallbladder carcinoma as diffusion in performing laparoscopic cholecystectomy. Asian J Surg
restriction is more common with XGC (68% vs. 7%) [84]. 40(5):367–374. https://​doi.​org/​10.​1016/j.​asjsur.​2015.​12.​006
XGC poses significant challenges to the radiologist and 7. Bennett GL, Rusinek H, Lisi V, Israel GM, Krinsky GA, Sly-
the surgeon. The diagnostic radiologist needs to identify wotzky CM, Megibow A (2002) CT findings in acute gangre-
nous cholecystitis. AJR Am J Roentgenol 178(2):275–281.
complications related to XGC and exclude the presence of https://​doi.​org/​10.​2214/​ajr.​178.2.​17802​75
malignancy. A laparoscopic approach is possible for XGC 8. Charalel RA, Jeffrey RB, Shin LK (2011) Complicated chol-
but is technically more complicated with much higher con- ecystitis: the complementary roles of sonography and computed
version rates to open cholecystectomy. tomography. Ultrasound Q 27(3):161–170. https://​doi.​org/​10.​
1097/​RUQ.​0b013​e3182​2a33e8
9. Harvey RT, Miller WT Jr (1999) Acute biliary disease: initial
CT and follow-up US versus initial US and follow-up CT. Radi-
Conclusion ology 213(3):831–836. https://​doi.​org/​10.​1148/​radio​logy.​213.3.​
r99dc​17831
10. Wu B, Buddensick TJ, Ferdosi H, Narducci DM, Sautter A,
Acute cholecystitis is a common ED diagnosis, and emer- Setiawan L, Shaukat H, Siddique M, Sulkowski GN, Kamangar
gency radiologists should be familiar with imaging find- F, Kowdley GC, Cunningham SC (2014) Predicting gangrenous
ings on both CT and US as the clinical presentation is cholecystitis HPB (Oxford) 16(9):801–806. https://​doi.​org/​10.​
variable, and the diagnosis may not be suspected clini- 1111/​hpb.​12226
11. Shapira-Rootman M, Mahamid A, Reindorp N, Nachtigal A, Zeina
cally. Additionally, there are several complicated forms AR (2015) Sonographic diagnosis of complicated cholecystitis. J
of cholecystitis requiring higher levels of patient care and

13
Emergency Radiology

Ultrasound Med 34(12):2231–2236. https://d​ oi.o​ rg/1​ 0.7​ 863/u​ ltra.​ cholecystitis and gallbladder rupture: CT findings. Abdom Imag-
14.​12072 ing 36(5):565–568. https://​doi.​org/​10.​1007/​s00261-​010-​9672-y
12. Wu CH, Chen CC, Wang CJ, Wong YC, Wang LJ, Huang 28. Patel NB, Oto A, Thomas S (2013) Multidetector CT of emergent
CC, Lo WC, Chen HW (2011) Discrimination of gangrenous biliary pathologic conditions. Radiographics 33(7):1867–1888.
from uncomplicated acute cholecystitis: accuracy of CT find- https://​doi.​org/​10.​1148/​rg.​33712​5038
ings. Abdom Imaging 36(2):174–178. https://​doi.​org/​10.​1007/​ 29. Jenkins M, Golding RH, Cooperberg PL (1983) Sonography and
s00261-​010-​9612-x computed tomography of hemorrhagic cholecystitis. AJR Am J
13 Catalano OA, Sahani DV, Kalva SP, Cushing MS, Hahn PF, Roentgenol 140(6):1197–1198. https://​doi.​org/​10.​2214/​ajr.​140.6.​
Brown JJ, Edelman RR (2008) MR imaging of the gallbladder a 1197
pictorial essay. Radiographics 28(1):135–155. https://​doi.​org/​10.​ 30. Hague J, Brennand D, Raja J, Amin Z (2010) Cystic artery
1148/​rg.​28106​5183 pseudoaneurysms in hemorrhagic acute cholecystitis. Cardio-
14. Tsai HM, Lin XZ, Chen CY, Lin PW, Lin JC (2004) MRI of vasc Intervent Radiol 33(6):1287–1290. https://​doi.​org/​10.​1007/​
gallstones with different compositions. AJR Am J Roentgenol s00270-​010-​9861-7
182(6):1513–1519. https://​doi.​org/​10.​2214/​ajr.​182.6.​18215​13 31. Watanabe Y, Nagayama M, Okumura A, Amoh Y, Katsube T,
15. Tonolini M, Ravelli A, Villa C, Bianco R (2012) Urgent MRI with Suga T, Koyama S, Nakatani K, Dodo Y (2007) MR imaging of
MR cholangiopancreatography (MRCP) of acute cholecystitis and acute biliary disorders. Radiographics 27(2):477–495. https://d​ oi.​
related complications: diagnostic role and spectrum of imaging org/​10.​1148/​rg.​27205​5148
findings. Emerg Radiol 19(4):341–348. https://​doi.​org/​10.​1007/​ 32. Yam MKH, Sim SW, Tam KY, Li YL (2020) A 51-year-old female
s10140-​012-​1038-z presenting with shock due to hemorrhagic cholecystitis. Radiol
16. Algin O, Ozlem N, Kilic E, Karaoglanoglu M, Arslan H (2010) Case Rep 15(12):2547–2549. https://d​ oi.o​ rg/1​ 0.1​ 016/j.r​ adcr.2​ 020.​
Gd-BOPTA-enhanced MR cholangiography findings in gall blad- 09.​045
der perforation. Emerg Radiol 17(6):487–491. https://​doi.​org/​10.​ 33. Baird DR, Wilson JP, Mason EM, Duncan TD, Evans JS, Luke
1007/​s10140-​010-​0886-7 JP, Ruben DM, Lucas GW (1992) An early review of 800 lapa-
17. Rodriguez LE, Santaliz-Ruiz LE, De La Torre-Bisot G, Gonzalez roscopic cholecystectomies at a university-affiliated community
G, Serpa MA, Sanchez-Gaetan F, Martinez-Trabal JL, Peguero- teaching hospital. Am Surg 58(3):206–210
Rivera JA, Bolanos-Avila G (2016) Clinical implications of hepa- 34. Ganapathi AM, Speicher PJ, Englum BR, Perez A, Tyler DS, Zani
tobiliary scintigraphy and ultrasound in the diagnosis of acute S (2015) Gangrenous cholecystitis: a contemporary review. J Surg
cholecystitis. Int J Surg 35:196–200. https://d​ oi.o​ rg/1​ 0.1​ 016/j.i​ jsu.​ Res 197(1):18–24. https://​doi.​org/​10.​1016/j.​jss.​2015.​02.​058
2016.​09.​084 35. Merriam LT, Kanaan SA, Dawes LG, Angelos P, Prystowsky JB,
18. Kwon JN (2012) Hemorrhagic cholecystitis report of a case. Rege RV, Joehl RJ (1999) Gangrenous cholecystitis analysis of
Korean J Hepatobiliary Pancreat Surg 16(3):120–122. https://​ risk factors and experience with laparoscopic cholecystectomy.
doi.​org/​10.​14701/​kjhbps.​2012.​16.3.​120 Surgery 126(4):680–685
19. Shishida M, Ikeda M, Karakuchi N, Ono K, Tsukiyama N, Shi- 36. Chang WC, Sun Y, Wu EH, Kim SY, Wang ZJ, Huang GS, Yeh
momura M, Oishi K, Miyamoto K, Toyota K, Sadamoto S, Taka- BM (2016) CT findings for detecting the presence of gangrenous
hashi T (2017) Hemorrhagic Cholecystitis in a Patient on Main- ischemia in cholecystitis. AJR Am J Roentgenol 207(2):302–309.
tenance Dialysis. Case Rep Gastroenterol 11(2):488–493. https://​ https://​doi.​org/​10.​2214/​AJR.​15.​15658
doi.​org/​10.​1159/​00047​9497 37. Cheng SM, Ng SP, Shih SL (2004) Hyperdense gallbladder wall
20. Hicks N (2014) Haemorrhagic cholecystitis: an unusual cause of sign: an overlooked sign of acute cholecystitis on unenhanced
upper gastrointestinal bleeding. BMJ Case Rep 2014. https://​doi.​ CT examination. Clin Imaging 28(2):128–131. https://​doi.​org/​10.​
org/​10.​1136/​bcr-​2013-​202437 1016/​S0899-​7071(03)​00196-7
21. Kinnear N, Hennessey DB, Thomas R (2017) Haemorrhagic chol- 38. Soyer P, Hoeffel C, Dohan A, Gayat E, Eveno C, Malgras B, Pau-
ecystitis in a newly anticoagulated patient. BMJ Case Rep 2017. trat K, Boudiaf M (2013) Acute cholecystitis: quantitative and
https://​doi.​org/​10.​1136/​bcr-​2016-​214617 qualitative evaluation with 64-section helical CT. Acta Radiol
22 Tarazi M, Tomalieh FT, Sweeney A, Sumner D, Abdulaal Y 54(5):477–486. https://​doi.​org/​10.​1177/​02841​85113​475798
(2019) Literature review and case series of haemorrhagic chol- 39. Kiviluoto T, Siren J, Luukkonen P, Kivilaakso E (1998) Ran-
ecystitis. J Surg Case Rep 9(1):360. https://​doi.​org/​10.​1093/​jscr/​ domised trial of laparoscopic versus open cholecystectomy for
rjy360 acute and gangrenous cholecystitis. Lancet 351(9099):321–325.
23. Zhang X, Zhang C, Huang H, Wang J, Zhang Y, Hu Q (2020) https://​doi.​org/​10.​1016/​S0140-​6736(97)​08447-X
Hemorrhagic cholecystitis with rare imaging presentation: a case 40. Iwashita Y, Ohyama T, Honda G, Hibi T, Yoshida M, Miura F,
report and a lesson learned from neglected medication history of Takada T, Han HS, Hwang TL, Shinya S, Suzuki K, Umezawa
NSAIDs. BMC Gastroenterol 20(1):172. https://​doi.​org/​10.​1186/​ A, Yoon YS, Choi IS, Huang WS, Chen KH, Watanabe M, Abe
s12876-​020-​01312-0 Y, Misawa T, Nagakawa Y, Yoon DS, Jang JY, Yu HC, Ahn
24. Pandya R, O’Malley C (2008) Hemorrhagic cholecystitis as a KS, Kim SC, Song IS, Kim JH, Yun SS, Choi SH, Jan YY,
complication of anticoagulant therapy: role of CT in its diag- Sheen-Chen SM, Shan YS, Ker CG, Chan DC, Lee KT, Toyota
nosis. Abdom Imaging 33(6):652–653. https://​doi.​org/​10.​1007/​ N, Higuchi R, Nakamura Y, Mizuguchi Y, Takeda Y, Ito M,
s00261-​007-​9358-2 Norimizu S, Yamada S, Matsumura N, Shindoh J, Sunagawa H,
25. Lauria AL, Bradley MJ, Rodriguez CJ, Franklin BR (2019) Hem- Hasegawa H, Rikiyama T, Sata N, Kano N, Kitano S, Tokumura
orrhagic Cholecystitis: an uncommon disease resulting in hemor- H, Yamashita Y, Watanabe G, Nakagawa K, Kimura T, Yam-
rhagic shock. Am Surg 85(6):e279–e281 akawa T, Wakabayashi G, Endo I, Miyazaki M, Yamamoto M
26. Gremmels JM, Kruskal JB, Parangi S, Kane RA (2004) Hemor- (2016) What are the appropriate indicators of surgical difficulty
rhagic cholecystitis simulating gallbladder carcinoma. J Ultra- during laparoscopic cholecystectomy? Results from a Japan-
sound Med 23(7):993–995. https://​doi.​org/​10.​7863/​jum.​2004.​ Korea-Taiwan multinational survey. J Hepatobiliary Pancreat
23.7.​993 Sci 23(9):533–547. https://​doi.​org/​10.​1002/​jhbp.​375
27. Tavernaraki K, Sykara A, Tavernaraki E, Chondros D, Lolis ED 41. Baker SR, Luk L, Clarkin K (2010) The trouble with fellow-
(2011) Massive intraperitoneal bleeding due to hemorrhagic ships. J Am Coll Radiol 7(6):446–451. https://​doi.​org/​10.​1016/j.​
jacr.​2010.​01.​020

13
 Emergency Radiology

42. Moanna A, Bajaj R, del Rio C (2006) Emphysematous cholecys- 59. Derici H, Kamer E, Kara C, Unalp HR, Tansug T, Bozdag AD,
titis due to Salmonella derby. Lancet Infect Dis 6(2):118–120. Nazli O (2011) Gallbladder perforation: clinical presentation,
https://​doi.​org/​10.​1016/​S1473-​3099(06)​70385-1 predisposing factors, and surgical outcomes of 46 patients. Turk
43. Chen YT, Ou SM, Chao PW, Li SY, Chen TJ, Tsai LW, Chen J Gastroenterol 22(5):505–512
TW (2013) Acute cholecystitis in end-stage renal disease 60. Jansen S, Stodolski M, Zirngibl H, Godde D, Ambe PC (2018)
patients: a nation-wide longitudinal study. Dig Liver Dis Advanced gallbladder inflammation is a risk factor for gall-
45(2):142–146. https://​doi.​org/​10.​1016/j.​dld.​2012.​08.​022 bladder perforation in patients with acute cholecystitis. World
44. Gill KS, Chapman AH, Weston MJ (1997) The changing face J Emerg Surg 13:9. https://​doi.​org/​10.​1186/​s13017-​018-​0169-2
of emphysematous cholecystitis. Br J Radiol 70(838):986–991. 61. Malik MN, Mahmood T, Din TU, A, Aslam S, Imtiaz M, (2019)
https://​doi.​org/​10.​1259/​bjr.​70.​838.​94041​99 Gallbladder perforation secondary to enteric fever: an interest-
45. Grayson DE, Abbott RM, Levy AD, Sherman PM (2002) ing case of acute abdomen. Cureus 11(4):e4516. https://​doi.​org/​
Emphysematous infections of the abdomen and pelvis: a picto- 10.​7759/​cureus.​4516
rial review. Radiographics 22(3):543–561. https://​doi.​org/​10.​ 62. Bedirli A, Sakrak O, Sozuer EM, Kerek M, Guler I (2001) Fac-
1148/​radio​graph​ics.​22.3.​g02ma​06543 tors effecting the complications in the natural history of acute
46. Wu CS, Yao WJ, Hsiao CH (1998) Effervescent gallbladder: cholecystitis. Hepatogastroenterology 48(41):1275–1278
sonographic findings in emphysematous cholecystitis. J Clin 63. Stefanidis D, Sirinek KR, Bingener J (2006) Gallbladder per-
Ultrasound 26(5):272–275. https://​doi.​org/​10.​1002/​(sici)​1097-​ foration: risk factors and outcome. J Surg Res 131(2):204–208.
0096(199806)​26:5%​3c272::​aid-​jcu9%​3e3.0.​co;2-9 https://​doi.​org/​10.​1016/j.​jss.​2005.​11.​580
47. Menakuru SR, Kaman L, Behera A, Singh R, Katariya RN 64. Boruah DK, Sanyal S, Sharma BK, Boruah DR (2016) Compar-
(2004) Current management of gall bladder perforations. ANZ ative evaluation of ultrasonography and cross-sectional imaging
J Surg 74(10):843–846. https://​doi.​org/​10.​1111/j.​1445-​1433.​ in determining gall bladder perforation in accordance to Nie-
2004.​03186.x meier’s classification. J Clin Diagn Res 10(8):15–18. https://​doi.​
48. Orlando R 3rd, Gleason E, Drezner AD (1983) Acute acalculous org/​10.​7860/​JCDR/​2016/​20158.​8318
cholecystitis in the critically ill patient. Am J Surg 145(4):472– 65. Niemeier OW (1934) Acute free perforation of the gall-bladder.
476. https://​doi.​org/​10.​1016/​0002-​9610(83)​90042-9 Ann Surg 99(6):922–924. https://​doi.​org/​10.​1097/​00000​658-​
49 Barie PS, Eachempati SR (2010) Acute acalculous cholecystitis. 19349​9060-​00005
Gastroenterol Clin North Am 39(2):343–357. https://​doi.​org/​10.​ 66. Anderson BB, Nazem A (1987) Perforations of the gallbladder
1016/j.​gtc.​2010.​02.​012 and cholecystobiliary fistulae: a review of management and a
50. Huffman JL, Schenker S (2010) Acute acalculous cholecystitis: new classification. J Natl Med Assoc 79(4):393–399
a review. Clinical gastroenterology and hepatology : the official 67. Patel G, Jain A, Kumar RB, Singh N, Karim T, Mishra R (2019)
clinical practice journal of the American Gastroenterological Gallbladder perforation: a prospective study of its divergent
Association 8(1):15–22. https://​doi.​org/​10.​1016/j.​cgh.​2009.​08.​ appearance and management. Euroasian J Hepatogastroenterol
034 9(1):14–19. https://​doi.​org/​10.​5005/​jp-​journ​als-​10018-​1289
51. Mirvis SE, Vainright JR, Nelson AW, Johnston GS, Shorr R, 68. Shakespear JS, Shaaban AM, Rezvani M (2010) CT findings of
Rodriguez A, Whitley NO (1986) The diagnosis of acute acal- acute cholecystitis and its complications. AJR Am J Roentgenol
culous cholecystitis: a comparison of sonography, scintigraphy, 194(6):1523–1529. https://​doi.​org/​10.​2214/​AJR.​09.​3640
and CT. AJR Am J Roentgenol 147(6):1171–1175. https://​doi.​ 69. Chau WK, Na AT, Feng TT, Li YB (1988) Ultrasound diagnosis
org/​10.​2214/​ajr.​147.6.​1171 of perforation of the gallbladder: real-time application and the
52. Kim SW, Kim HC, Yang DM, Won KY, Moon SK (2015) Cystic demonstration of a new sonographic sign. J Clin Ultrasound
duct enhancement: a useful CT Finding in the diagnosis of acute 16(5):358–360. https://​doi.​org/​10.​1002/​jcu.​18701​60512
cholecystitis without visible impacted gallstones. AJR Am J 70. Sood BP, Kalra N, Gupta S, Sidhu R, Gulati M, Khandelwal N,
Roentgenol 205(5):991–998. https://​doi.​org/​10.​2214/​AJR.​15.​ Suri S (2002) Role of sonography in the diagnosis of gallbladder
14403 perforation. J Clin Ultrasound 30(5):270–274. https://​doi.​org/​
53. Akhan O, Akinci D, Ozmen MN (2002) Percutaneous cholecys- 10.​1002/​jcu.​10071
tostomy. Eur J Radiol 43(3):229–236. https://​doi.​org/​10.​1016/​ 71. Kim PN, Lee KS, Kim IY, Bae WK, Lee BH (1994) Gallbladder
s0720-​048x(02)​00158-4 perforation: comparison of US findings with CT. Abdom Imag-
54. Chung YH, Choi ER, Kim KM, Kim MJ, Lee JK, Lee KT, Lee ing 19(3):239–242. https://​doi.​org/​10.​1007/​BF002​03516
KH, Choo SW, Do YS, Choo IW (2012) Can percutaneous chol- 72. Lee S, Kwon J, Kim K (2018) Laparoscopic management of
ecystostomy be a definitive management for acute acalculous massive intraperitoneal haemorrhage caused by an acute gall-
cholecystitis? J Clin Gastroenterol 46(3):216–219. https://​doi.​ bladder perforation. J Minim Access Surg 14(1):65–67. https://​
org/​10.​1097/​MCG.​0b013​e3182​274375 doi.​org/​10.​4103/​jmas.​JMAS_​98_​17
55. Peters R, Kolderman S, Peters B, Simoens M, Braak S (2014) 73. Singh VP, Rajesh S, Bihari C, Desai SN, Pargewar SS, Arora A
Percutaneous cholecystostomy: single centre experience in 111 (2016) Xanthogranulomatous cholecystitis: what every radiolo-
patients with an acute cholecystitis. JBR-BTR 97(4):197–201. gist should know. World J Radiol 8(2):183–191. https://​doi.​org/​
https://​doi.​org/​10.​5334/​jbr-​btr.​101 10.​4329/​wjr.​v8.​i2.​183
56. Winbladh A, Gullstrand P, Svanvik J, Sandstrom P (2009) 74. Houston JP, Collins MC, Cameron I, Reed MW, Parsons MA,
Systematic review of cholecystostomy as a treatment option in Roberts KM (1994) Xanthogranulomatous cholecystitis. Br J
acute cholecystitis. HPB (Oxford) 11(3):183–193. https://​doi.​ Surg 81(7):1030–1032. https://​doi.​org/​10.​1002/​bjs.​18008​10735
org/​10.​1111/j.​1477-​2574.​2009.​00052.x 75. Dao AH, Wong SW, Adkins RB Jr (1989) Xanthogranulomatous
57. Balmadrid B (2018) Recent advances in management of acalcu- cholecystitis A clinical and pathologic study of twelve cases. Am
lous cholecystitis. F1000Res 7. https://​doi.​org/​10.​12688/​f1000​ Surg 55(1):32–35
resea​rch.​14886.1 76. Levy AD, Murakata LA, Abbott RM, Rohrmann CA Jr (2002)
58. Ausania F, Guzman Suarez S, Alvarez Garcia H, Senra del From the archives of the AFIP Benign tumors and tumorlike
Rio P, Casal Nunez E (2015) Gallbladder perforation: morbid- lesions of the gallbladder and extrahepatic bile ducts radiologic-
ity, mortality and preoperative risk prediction. Surg Endosc pathologic correlation Armed Forces Institute of Pathology.
29(4):955–960. https://​doi.​org/​10.​1007/​s00464-​014-​3765-6

13
Emergency Radiology

Radiographics 22(2):387–413. https://d​ oi.o​ rg/1​ 0.1​ 148/r​ adiog​ raph​ 82. Goshima S, Chang S, Wang JH, Kanematsu M, Bae KT, Federle
ics.​22.2.​g02mr​08387 MP (2010) Xanthogranulomatous cholecystitis: diagnostic perfor-
77. Guzman-Valdivia G (2005) Xanthogranulomatous cholecystitis mance of CT to differentiate from gallbladder cancer. Eur J Radiol
in laparoscopic surgery. J Gastrointest Surg 9(4):494–497. https://​ 74(3):e79-83. https://​doi.​org/​10.​1016/j.​ejrad.​2009.​04.​017
doi.​org/​10.​1016/j.​gassur.​2004.​09.​036 83. Zhao F, Lu PX, Yan SX, Wang GF, Yuan J, Zhang SZ, Wang YX
78. Parra JA, Acinas O, Bueno J, Guezmes A, Fernandez MA, Farinas (2013) CT and MR features of xanthogranulomatous cholecystitis:
MC (2000) Xanthogranulomatous cholecystitis: clinical, sono- an analysis of consecutive 49 cases. Eur J Radiol 82(9):1391–
graphic, and CT findings in 26 patients. AJR Am J Roentgenol 1397. https://​doi.​org/​10.​1016/j.​ejrad.​2013.​04.​026
174(4):979–983. https://​doi.​org/​10.​2214/​ajr.​174.4.​17409​79 84. Kang TW, Kim SH, Park HJ, Lim S, Jang KM, Choi D, Lee SJ
79. Kim PN, Ha HK, Kim YH, Lee MG, Kim MH, Auh YH (1998) (2013) Differentiating xanthogranulomatous cholecystitis from
US findings of xanthogranulomatous cholecystitis. Clin Radiol wall-thickening type of gallbladder cancer: added value of dif-
53(4):290–292. https://​doi.​org/​10.​1016/​s0009-​9260(98)​80129-3 fusion-weighted MRI. Clin Radiol 68(10):992–1001. https://​doi.​
80. Zhang F, Chen W, Zhang L, Hou C, Zhang M (2019) Usefulness org/​10.​1016/j.​crad.​2013.​03.​022
of ultrasound in differentiating xanthogranulomatous cholecystitis
from gallbladder carcinoma. Ultrasound Med Biol 45(11):2925– Publisher’s note Springer Nature remains neutral with regard to
2931. https://​doi.​org/​10.​1016/j.​ultra​smedb​io.​2019.​07.​682 jurisdictional claims in published maps and institutional affiliations.
81. Revzin MV, Scoutt L, Smitaman E, Israel GM (2015) The gall-
bladder: uncommon gallbladder conditions and unusual pres-
entations of the common gallbladder pathological processes.
Abdom Imaging 40(2):385–399. https:// ​ d oi. ​ o rg/ ​ 1 0. ​ 1 007/​
s00261-​014-​0203-0

13