2020 Volume 69 Issue 3 Pages 457-462
A woman in her seventies developed sudden cardiac pain during hospitalization for rehabilitation purposes after orthopedic surgery. Laboratory tests showed elevated alkaline phosphatase, C-reactive protein, and CA19-9 levels in serum, suggesting the presence of a biliary disease. Ultrasonography revealed a heterogeneous hyperechoic region in the gallbladder, which showed no blood flow signal with color Doppler, and a heterogeneous hyperechoic region protruding from the gallbladder to the left hepatic lobe. Three days after the symptom onset, computed tomography revealed enlargement of the gallbladder along with the thickening and partial disappearance of the gallbladder wall. In the liver, a low-density area, which was considered to indicate fluid retention, was observed with an abscess around the gallbladder. On the basis of these findings, acute cholecystitis and gallbladder perforation with intrahepatic rupture were suspected; however, conservative treatment was opted considering the patient’s age. Ultrasonography of the liver, which was performed 14 days after the symptom onset, revealed the disappearance of the heterogeneous hyperechoic region in the gallbladder, but disruption of the gallbladder wall was confirmed. The possibility of gallbladder hemorrhage and perforation due to a neoplastic lesion was also considered, but subsequent evaluations did not show inflammatory reactions and liver function deterioration. The imaging findings showed improvements; therefore, the patient was only followed up. In acute cholecystitis, hemorrhagic cholecystitis and gallbladder perforation are signs of aggravation, and their prompt diagnoses are important. Ultrasonography is the first imaging test of choice when cholecystitis is suspected, and careful observation is necessary to not overlook findings indicative of aggravation.
