Skip to content PERICHOLECYSTIC ABSCESS PRESENTING AS PANCREATIC HEAD MASS Reema Agarwal1, jad Tabbara, Keniesha Thompson, M.D., 1SSM SLU Hospital, MO, SAINT LOUIS Case Presentation: We present a 42-year-old Caucasian female patient who presented with [shmabstracts.org]

METHOD: Data were retrospectively collected from clinical case notes and a literature review is presented. [ncbi.nlm.nih.gov]

Omental inflammation surrounding the GB was present in 5 cases at surgery. [em-consulte.com]

Best modality for identifying intramural/intraluminal gallbladder (GB) gas (100% sensitive) Gas within pericholecystic abscess or free intraperitoneal air may be present with perforation Other CT findings similar to uncomplicated cholecystitis • Ultrasound [radiologykey.com]

• Fever

  Nausea, vomiting, abdominal pain and fever are characteristic. Fever should typically be low grade and last 1 week [ 1 ]. Gallbladder infarction is rare and reported at 1.1% [ 2 ]. [intjem.biomedcentral.com]

  Grande-Pérez, Jaqueline de Jesus Pereira, Fellippo Ramos Published in Revista espanola de enfermedades digestivas… 2009 A 75-year-old male patient with recurrent biliary colics attends the emergency service because of right upper-quadrant abdominal pain and fever [semanticscholar.org]

  Clinical History 90-year-old man with dementia presenting with abdominal pain and fever. Physical examination showed non-specific findings. Lab work-up revealed elevated WBC count and inflammatory markers. [eurorad.org]

  No fever of leukocytosis. [aast.org]

  Expect fever to resolve in 24 hours and diarrhea within 4-5 days [NEJM 346: 334, 2002]. [openanesthesia.org]

• Congestive Heart Failure

  Some of these include acute cholecystitis, renal failure, cirrhosis, pancreatitis, primary gallbladder carcinoma, acute acalculous cholecystitis (AAC), congestive heart failure, and hepatitis. [verywellhealth.com]

• Malaise

  Fever and malaise for 3 days. Patient Data Age: 77 Gender: Male Loading images... Axial C+ portal venous phase Low-attenuation lesion in the liver adjacent to the gallbladder with subtle peripheral enhancement. Loading images... [radiopaedia.org]

  On the other hand patients may also show weakness, malaise and a palpable right upper quadrant mass, mimicking a malignacy. [wjes.biomedcentral.com]

  […] prolonged (> 6 hours) than in biliary colic Postprandial Radiation to the right scapula (due to referred pain from phrenic nerve irritation) Positive Murphy sign: sudden pausing during inspiration upon deep palpation of the RUQ due to pain Guarding Fever, malaise [www-amboss-com.db.rsu.lv]

• Fatigue

  Nonspecific symptoms include diarrhea, upset stomach, fatigue, altered mental status, and jaundice. Hemorrhagic AAC has been reported in patients with end-stage renal disease (ESRD). [rarediseases.org]

• Abdominal Pain

  Esophageal Perforation AAST Grade Description Clinical Criteria Imaging and/or endoscopic criteria Operative Criteria Pathologic criteria I Mucosal tear Dysphagia; chest pain, upper abdominal pain or back pain; breathing problems No abnormality or possible [aast.org]

  A 75-year-old male was admitted to the hospital because of a sudden onset of right upper abdominal pain after a lunch. Abdominal CT scan findings of the gallbladder performed preoperatively had a strange shape which seemed like a record disk. [jstage.jst.go.jp]

  pain and fever for two days. [semanticscholar.org]

  […] presentation An 80 year old male patient was admitted to our hospital with abdominal pain for 3 to 4 days. [openaccessjournals.com]

• Right Upper Quadrant Pain

  MRCP can be helpful in diagnosis of clinically silent gallbladder perforation in patients with right upper quadrant pain. [experts.umn.edu]

  Articles will include: Evaluating the patient with right upper quadrant pain; Evaluating the patient with left upper quadrant pain; Evaluating the patient with right lower quadrant pain; Evaluating the patient with left lower quadrant pain; Acute pancreatitis [books.google.com]

  Case study, Radiopaedia.org (Accessed on 28 Nov 2022) https://doi.org/10.53347/rID-68313 Institution: Augusta University Inclusion in quiz mode: Included Presentation Chronic recurrent right upper quadrant pain abdomen in a veteran. [radiopaedia.org]

  Some may present early with right upper quadrant pain, while others may present with tea-colored urine after a perforation.Review all imaging to ensure accurate diagnosis prior to verbalizing potential diagnoses to patients.Further research is necessary [shmabstracts.org]

• Epigastric Pain

  Case study, Radiopaedia.org (Accessed on 28 Nov 2022) https://doi.org/10.53347/rID-24532 Inclusion in quiz mode: Included + add to new playlist Presentation Nausea, vomiting, and epigastric pain. [radiopaedia.org]

  pain for few months prior to presentation. [shmabstracts.org]

  The clinical presentation of pancreatitis varies from case to case, with epigastric pain, nausea and vomiting being the commonest symptoms as observed in the present case. [ijpmonline.org]

  There is no evidence to link gallstones with epigastric pain, belching or indigestion. Heartburn and reflux symptoms are not directly related to the presence of gallstones. [gponline.com]

  Acute Cholecystitis AAST Grade Description Clinical Criteria Imaging Criteria (CT/US/HIDA findings) Operative Criteria Pathologic Criteria I Acute cholecystitis Right upper quadrant (RUQ) or epigastric pain; Murphy’s Sign; leukocytosis Wall thickening [aast.org]

• Severe Abdominal Pain

  Severe abdominal pain referred to the patient's back, nausea, vomiting, and high serum and urinary amylase values were compatible with acute pancreatitis. [link.springer.com]

  If your gallbladder ruptures, you may have sudden, sharp severe abdominal pain. The pain might be short-lived after the rupture. But the pain often returns when the rupture site with leaking content grows or becomes inflamed or infected. [healthline.com]

  abdominal pain, particularly if the pain lasts longer than a few hours or is accompanied by other symptoms, such as jaundice and a fever. [nhsinform.scot]

  The pain becomes more severe and constant in cholecystitis. [en.wikipedia.org]

• Tachycardia

  Examination revealed a markedly obese, dehydrated patient with tachycardia and tachypnoea. A large, tender and non-mobile mass was palpable in the right lumbar and iliac regions of the abdomen, extending from the right flank up to the umbilicus. [bioline.org.br]

  On examination the patient may look septic with systemic signs of infection (pyrexia and tachycardia) and local RUQ peritonism. Murphy's sign is usually positive. [gponline.com]

  Hernia visible on CT Abdominal wall defect present with abdominal contents lodged in defect; healthy appearing viscera N/A III Incarcerated with bowel ischemic but viable Local tenderness with non-reducible palpable hernia; may be associated with fever, tachycardia [aast.org]

  […] ulcer)吻合部潰瘍 subacute bacterial endocarditis 亜急性細菌性心内膜炎 subacute hepatic necrosis亜急性肝壊死 submucosal layer粘膜下層 superficial gastritis表層性胃炎 superior mesenteric artery syndrome (arteriomesenteric occlusion of duodenum)上腸間膜動脈症候群 suppository坐薬 swallowing嚥下運動 t tachycardia [tokyo-med.ac.jp]

  Fever and tachycardia are commonly absent in acute cholecystitis; maintain a high index of clinical suspicion! [www-amboss-com.db.rsu.lv]

• Murphy's Sign

  […] attention to clinical status important when assessing for sonographic Murphy’s sign Rubens DJ. [slideshare.net]

  Cholelithiasis, sonographic Murphy sign, and GB wall thickening • CT findings Distended GB (measuring > 5 cm in short axis) GB wall thickening (> 3 mm) with mural and mucosal hyperenhancement and pericholecystic fat stranding Calcified gallstones may [clinicalgate.com]

  The patient experiences pain when palpated on the right hypochondrium, with Murphy’s sign and a temperature of 38 oC. [semanticscholar.org]

  Examples include GB thickening, calculi in the GB, a positive ultrasonographic Murphy sign, and pericholecystic fluid. The sonographic Murphy sign is negative in as many as 70% of patients with AC. [emedicine.medscape.com]

  May progress to complicated cholecystitis rapidly and w/o warning Physical Exam/Signs General, Vitals: fever, guarded, positive Murphy sign, jaundice (15%) Murphy's sign had highest specificity (79-96%) but low sensitivity (20-87.5%) Absence of physical [fprmed.com]

• Jaundice

  Symptoms include vomiting, abdominal bloating, fever, nausea, jaundice, and body chills. [healthresearchfunding.org]

  Anomalous insertion of cystic duct (Cystic duct & CHD are parallel) -Impacted stone in cystic duct, cystic duct remnant or GB neck -Inflammatory reaction around impacted stone causing partial obstruction of CHD Cystic Duct & CHD Obstruction leads to: -Jaundice [quizlet.com]

  […] as soon as possible if you develop sudden and severe abdominal pain, particularly if the pain lasts longer than a few hours or is accompanied by other symptoms, such as jaundice and a fever. [nhsinform.scot]

  Yellowing of the skin (jaundice) may occur but is often mild. [en.wikipedia.org]

  The clinical features of perforation or hepatic abscess include fever, pain and jaundice but the clinical course might be insidious with non specific laboratory findings. [3] Furthermore, patients are usually of advanced age, clinical history is not always [eurorad.org]

• Biliary Colic

  colics attends the emergency service because of right upper-quadrant abdominal pain and fever for two days. [semanticscholar.org]

  Biliary colic Biliary colic occurs when a gallstone impacts in the neck of the gallbladder obstructing the cystic duct. The pain resolves spontaneously as the stone falls back into the gallbladder or passes into the common bile duct (CBD). [gponline.com]

  […] tract cancers. 12 Biliary Colic The pain of biliary colic occurs when the gallbladder contracts, forcing a stone and/or sludge against the gallbladder neck or opening of the cystic duct. [ahcmedia.com]

  Pyelonephritis Presentation History Right upper quadrant (RUQ) pain History of similar, self-limited pain (biliary colic) Nausea/Vomiting Radiation of pain to the tip of the right scapula (referred pain) Physical Examination RUQ/epigastric tenderness [coreem.net]

  colic.[1] Biliary colic is abdominal pain in the right upper quadrant or epigastric region. [en.wikipedia.org]

• Liver Mass

  […] and biliary (MRCP); MR of kidney and adrenal glands; prostate MR; MR of focal liver masses; MR of pancreas; MR enterography; gadolinium contrast agent selection and optimal use for body MRI; MR angiography and venography of abdomen and pelvis; functional [books.google.com]

  Liver abscess secondary to intrahepatic perforation of the gallbladder, presenting as a liver mass. Am J Gastroenterol. 1996;91:1644–6. Ceylan H, Sirikci A, Ozokutan BH, Bayram M, Sivasli E. [tropicalgastro.com]

  […] is significant for carcinoma "Constrained Stone Sign" -GB Wall thickened and hypoechoic -GB poorly distinguished from the liver GB carcinoma metastasize to: -Cystic duct -Adjacent bile duct -Liver -When lesions extend into liver masses may lie in contact [quizlet.com]

  Bakalakos EA, Melvin WS, Kirkpatrick R: Liver abscess secondary to intrahepatic perforation of the gall bladder, presenting as a Liver mass. Am J Gastroenterol 1996;91:1644-1646. 13. [jemds.com]

• Gallbladder Tenderness

  The gallbladder may be encased in inflammatory mass Toxic patient RUQ pain and tenderness Swinging pyrexia Tender RUQ mass Rarely responds to conservative measures. [gponline.com]

• Suggestibility

  These data suggest that not only can biliary sonography aid in the diagnosis of acute cholecystitis, calculous as well as acalculous, but can also visualize a pericholecystic abscess when it is present. [ncbi.nlm.nih.gov]

  In the fundus of the gallbladder, there was a defective image in the anterior plane, suggesting gallbladder perforation (FÄ°GURES 1A & 1B). [openaccessjournals.com]

  Findings on MRI suggestive of chronic cholecystitis include thickening of the gallbladder and gallstones. [wikidoc.org]

  Kocher et al.[8] have suggested that the declining incidence of gallbladder perforation may be attributable to earlier and better management of symptomatic calculi. [tropicalgastro.com]

  […] of acalculous cholecystitis should suggest the possibility of other causes of pericholecystic fluid. [emedicine.medscape.com]

The definitive diagnosis can only be made on histological and bacteriological workup. [acgcasereports.gi.org]

[…] other abdominal structures (can identify an alternative diagnosis), provides preoperative information such as gallbladder size, stone size, gallbladder wall status and the presence of biliary dilatation 19 The addition of a HIDA scan in the diagnostic workup [imagingpathways.health.wa.gov.au]

Tests to rule out differential diagnoses: See “Diagnostic workup of acute abdominal pain.” Imaging [9][10] RUQ transabdominal ultrasound See also “Biliary point-of-care ultrasound.” [www-amboss-com.db.rsu.lv]

If this is the case, laboratory tests and an ultrasound should be obtained as part of the initial workup. For patients who are ultimately diagnosed with biliary colic, outpatient surgical follow-up should be arranged. [ahcmedia.com]

• Neutrophilia

  Laboratory studies revealed leukocytosis with neutrophilia (15,000 leukocytes/mm3, 80% neutrophils) with hepatic enzymes and normal pancreatic amylase. An initial ultrasound exam was performed, which showed evidence of… CONTINUE READING [semanticscholar.org]

  Laboratory studies revealed leukocytosis with neutrophilia (15,000 leukocytes/mm3, 80% neutrophils) with hepatic enzymes and normal pancreatic amylase. [scielo.isciii.es]

Application of laparoscopic appendectomy to treatment of periappendiceal abscess 腹腔镜治疗阑尾周围脓肿的应用 2. [dictall.com]

Treatment To treat a pericholecystic abscess, early diagnosis and intervention is the key to successful outcomes. The initial treatment for gallbladder perforation may be percutaneous cholecystostomy. [verywellhealth.com]

Prognosis Gallbladder perforation with pericholecystic abscess is a rare disorder. It is considered a life-threatening, emergency complication of acute cholecystitis. [verywellhealth.com]

• The etiology of emphysematous cholecystitis is controversial, but it is considered to be due to ischemia of the gallbladder from primary vascular compromise, with secondary proliferation of gas-producing bacteria. 13. limited• Note:• Wall thickening [slideshare.net]

[…] sign • Radiography : Insensitive for detection of ectopic gas • MR : Intraluminal and intramural gas appear as signal voids on all pulse sequences PATHOLOGY • Infection of GB with gas-forming organisms such as Clostridium welchii and Escherichia coli • Etiology [radiologykey.com]

[…] of all cases of acute cholecystitis Occurs more often in men As opposed to gallbladder disease in general which occurs more often in women Mostly are elderly patients (>60) with diabetes Vascular compromise of the cystic artery may play a role in the etiology [learningradiology.com]

Focal sclerosing cholangitis -Primary liver tumor -Tumor of duct Complications of Gallstones -Porcelain GB -Milk of Calcium Bile -Cholecystitis -95% associated with gallstones -5 times more common in females -11-33% carcinomas have calcification in wall Etiology [quizlet.com]

[…] wall perforations covered up by surrounding tissue forming abscesses Biliary fistula: duodenal-gallbladder fistula formation, usually d/t erosion of wall into duodenum by large stone; stone can travel to ileocecal valve and cause SBO (gallstone ileus) Etiology [fprmed.com]

Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines.. [www-amboss-com.db.rsu.lv]

Epidemiology of gallbladder disease: Cholelithiasis and cancer. Gut Liver 2012;6:172-87. 2. Unisa S, Jagannath P, Dhir V, Khandelwal C, Sarangi L, Roy TK. [ijri.org]

Incidence/Prevalence No large epidemiological study to date, but estimated 10% US pop has gallstones Up to 12% develop acute cholecystitis (most frequent complication of gallstones) after 5-7 yrs Up to 6% develop severe acute cholecystitis Prevalence [fprmed.com]

Epidemiology Due to the rarity of the condition, the available information are limited. The affected patients are usually older females. When questioned, patients may mention previous episodes of right upper quadrant pain. [statpearls.com]

"Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines". Journal of Hepato-Biliary-Pancreatic Surgery. 14 (1): 15–26. doi:10.1007/s00534-006-1152-y. ISSN 0944-1166. PMC 2784509. [en.wikipedia.org]

[…] of the biliary outflow by a gallstone is thought to play a significant role in the pathophysiology of the development of this condition. [statpearls.com]

This complication occurs in 2-10% of cases of acute cholecystitis. (1) With the increase in cholecystectomies in modern surgical practice, gallbladder perforation is becoming rare with a reported incidence of 0.8%. (2) The pathophysiology leading to perforation [appliedradiology.com]

Pathophysiology Cystic duct obstruction is the proximate cause of cholecystitis Obstruction leads to gallbladder distension An inflammatory reaction occurs due to either mucosal ischemia from increased hydrostatic pressure or cytotoxic effects of bile [coreem.net]

Sleisenger & Fordtran's Gastrointestinal and liver disease pathophysiology, diagnosis, management (9 ed.). [S.l.]: MD Consult. p. 1065. ISBN 9781437727678. [en.wikipedia.org]

On the contrary, the indications for such intervention are always widening, as its risks become always smaller and the requirements for prevention higher. [books.google.ro]

Read more about preventing gallstones. [nhsinform.scot]

Prevention You can reduce your risk of cholecystitis by taking the following steps to prevent gallstones: Lose weight slowly. Rapid weight loss can increase the risk of gallstones. [mayoclinic.org]

Dr Sern Chin Lim Dr International Medical Universitry Malaysia Primary Prophylaxis to Prevent the Development of Hepatic Encephalopathy in Cirrhotic Patients with Acute Variceal Bleeding. [pubfacts.com]

Relapses occur in 25% of cases, but 75% of these will respond to the same antibiotic if repeated [Lancet ID 5: 549, 2005] Prevention of C.difficile Prevention is primarily by rational antibiotic use and possibly the use of probiotics (in one study, 1 [openanesthesia.org]