Presentation: 60 year old male with right upper quadrant pain x weeks.

Key imaging findings (listed in bullet point format):

• Irregular contour to the fundus of the gallbladder
• Gallstone impacted at the neck of the gallbladder
• Gallbladder wall thickening
• Fat stranding
• Geographic edema of the adjacent liver parenchyma

Diagnosis: Acute cholecystitis with gallbladder perforation

Recommendations for optimal image interpretation: Look at the gallbladder/ducts in both the axial and the coronal

Management:

Operative note key text:

1) Extremely edematous, firm gallbladder with hydrops

2) A single stone at the neck of the infundibulum obstructing the cystic duct 

3) Large perforation at the dome of the gallbladder

2) Significant adhesive disease from the omentum, transverse colon and duodenum to the perforated dome of the gallbladder

3) Friable tissues

Pathology report key text: Acute cholecystitis with perforation. Hemorrhagic mucosa.

Case discussion: In this 60 year old male with weeks of RUQ pain, the CT abdomen/pelvis revealed an irregular contour of the gallbladder, in the setting of gallbladder wall thickening, impacted gallstone, edema, and fat stranding. The perforated gallbladder was confirmed during his open cholecystectomy the next day.

1. Occlusion of the cystic duct leads to increased gallbladder pressure, and ultimately to ischemia and necrosis of the gallbladder wall, predisposing the patient for gallbladder perforation.
2. The mortality rate for perforated acute cholecystitis is 12-16%.
3. Complications of perforated cholecystitis that may be seen on follow-up imaging include bile peritonitis, abscess formation, pneumonia, and pancreatitis.

https://radiopaedia.org/articles/gallbladder-perforation?lang=us