Case Study

03_00238 Jett K Cholecystitis-potential rupture

A 10-year-old NM DSH with a history of chronic intermittent vomiting over 1 month was presented for a 3-day duration of anorexia and protracted vomiting. Abnormalities on physical examination were weight loss and icteric mucus membranes. Serum biochemistry showed bilirubinemia, elevated ALT activity (1670), and low BUN.

A 10-year-old NM DSH with a history of chronic intermittent vomiting over 1 month was presented for a 3-day duration of anorexia and protracted vomiting. Abnormalities on physical examination were weight loss and icteric mucus membranes. Serum biochemistry showed bilirubinemia, elevated ALT activity (1670), and low BUN.

Sonographic Differential Diagnosis

Cholecystitis with potential rupturing gallbladder. Concurrent right limb pancreatitis. Minor periportal lymphadenopathy. I strongly recommend surgical intervention with cholecystectomy, liver biopsy and common bile duct lavage. Periportal lymph node biopsy as well as right limb pancreatic biopsy would all be ideal. If medical therapy is to be performed in this patient the gallbladder needs to be monitored as there is evidence of necrosis of the gallbladder itself. I strongly recommend a cholecystectomy in this patient as the gallbladder is likely useless and will continue to be a problem over time if the patient stabilizes. Guarded prognosis.

Image Interpretation

The liver in this patient was coarse in architecture with increased portal markings and thickened gallbladder. Thickened gallbladder and tortuous cystic duct were noted. This is consistent with cholangiohepatitis. Cranial to the gallbladder wall was free fluid and double layered wall. I strongly recommend a cholecystectomy in this patient with liver biopsy. Minor periportal lymphadenopathy was noted.

DX

Cholecystitis-potential rupture

Outcome

The patient passed away.

Clinical Differential Diagnosis

Liver – cholangiohepatitis complex, lipidosis, neoplasia, infectious (bacterial, fungal, viral), toxic Gall bladder – obstruction, cholecystitis Pancreas – pancreatitis, neoplasia GI tract – IBD, neoplasia, partial duodenal obstruction