CASE 14933 Published on 15.09.2017

Acute acalculous cholecystitis due to salmonella enterocolitis

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Barón Ródiz P, Poyo Calvo C, De Luis Yanes J, Pérez De Los Ríos A

Department of Radiology,
Hospital Universitario Severo Ochoa,
Madrid, Spain
Email:pao_baron@hotmail.com
Patient

61 years, female

Categories
Area of Interest Abdomen, Colon, Gastrointestinal tract, Biliary Tract / Gallbladder, Emergency ; Imaging Technique Ultrasound
Clinical History

A 61-year-old female patient presented to the ER with diarrhoea, nausea, vomiting and 38.5 ºC temperature.
Physical examination showed normal results.
Laboratory test disclosed a white cell count of 8179/mm3 with 88% of neutrophils and 10% lymphocytes.
Coproculture obtained on admission was positive for Salmonella enteritidis.
An abdominal ultrasound (US) was performed.

Imaging Findings

Abdominal US showed a distended gallbladder with a markedly thick wall with sonolucent intramural layers (intramural oedema) with no stones. The gallbladder was surrounded by a little fluid collection and Murphy’s sign was positive; all these findings were compatible with an acute acalculous cholecystitis (AAC) (Fig. 1).
Also, abdominal US disclosed a marked mucosal thickening affecting the terminal ileum, caecum and ascending colon, suggestive of enterocolitis (Fig. 2).

Discussion

Acute acalculous cholecystitis (AAC) is an acute inflammation of the gallbladder in the absence of stones. It accounts for 5 – 14 % of all cases of acute cholecystitis (AC) and tends to occur in critically ill patients [1 – 3].

Its pathogenesis is unclear to date. Multiple risk factors have been described such as visceral atherosclerosis and previous surgery, trauma or burn injury [1 – 3].

AAC may also occur from secondary infection of the gallbladder following a systemic infection by multiple organisms, but it is a rare condition [4, 5] as it is probably happening in our case.

Salmonellosis has many types of presentation: enterocolitis (the most common), enteric fever (typhoid and paratyphoid fevers), bacteraemia, localised infections, and chronic carrier state. AAC is an unusual complication of salmonella enterocolitis and may occur weeks after diarrhoea has stopped [6, 7].

In our case, the patient developed a right upper quadrant pain two days after the onset of the diarrhoea and had a positive Murphy’s sign.

The role of US and CT in the diagnosis of AAC is limited because non-specific gallbladder abnormalities are common in critically ill patients (dilation, wall thickening and fluid may be seen) [8, 9].

Cholescintigraphy may be a more sensitive diagnostic test because most cases of AAC are associated with cystic duct obstruction. However, some cases of AAC are related to direct inflammation of the gallbladder, leading to false negative studies [10].

CT may be helpful in equivocal cases or to identify complications [11].

MR has not been evaluated sufficiently in AAC. However, it may be useful in critically ill patients who often have borderline renal function. Increased gallbladder wall enhancement and increased transient pericholecystic hepatic parenchymal enhancement may be discriminative findings to differentiate between acute and chronic cholecystitis [12].

In our case, US disclosed findings compatible with AAC and findings suggestive of enterocolitis; both were probably due to Salmonella enteritidis.

Although most cases described in the literature have required surgical intervention, AAC may be conservatively managed with supportive therapy and appropriate antibiotics in non-critically ill patients.

In our case, the patient received a conservative treatment with fluids and intravenous antibiotics having a good outcome and cholecystitis was resolved after three weeks of treatment (Fig. 3).

Take Home Message:

AAC is an unusual complication of salmonella enterocolitis.
US is the preferred initial imaging test, with supplemental cholescintigraphy in problematic cases. CT or MR may be helpful in equivocal cases or to identify complications.

Differential Diagnosis List
Acute acalculous cholecystitis due to salmonella enterocolitis.
Calculous acute cholecystitis
Chronic cholecystitis
Xanthogranulomatous cholecystitis
Adenomyomatosis
Gallbladder carcinoma
Gallbladder wall oedema due to cirrhosis
Hepatitis
Final Diagnosis
Acute acalculous cholecystitis due to salmonella enterocolitis.
Case information
URL: https://www.eurorad.org/case/14933
DOI: 10.1594/EURORAD/CASE.14933
ISSN: 1563-4086
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