CT Case 036
A 92-year-female presents with RUQ pain, back pain, fevers and vomiting. Symptoms had been ongoing for the last 24 hours.
She looks systemically unwell. Vitals include:
- Temp 38,
- SBP 87, HR 140 (sinus tachycardia)
- RR 26, Saturation 88% RA
On examination she is GCS 14 with scleral icterus and Murphy’s sign positive on abdominal examination. On point-of-care testing she has a lactate of 7.3.
An abdominal CT scan is performed
Describe and interpret the CT images
CT INTERPRETATION
There is hypoenhancement of the body of the pancreas with surrounding fat stranding suggestive of necrotizing pancreatitis.
There is a round calculus in the neck of the gallbladder with pericholecystic fat stranding and gallbladder wall thickening in keeping with cholelithiasis with cholecystitis.
There is dilatation of the common bile duct (CBD) as well as intrahepatic biliary ducts. There is enhancement of the CBD wall which likely represents cholangitis.
This CT shows cholelithiasis and cholecystitis which has caused the pancreatitis and cholangitis. Cholangitis on CT appears as diffuse thickening and enhancement of the CBD and common hepatic duct usually in the context of CBD obstruction.
Though CT does show these features, it needs to be interpreted with appropriate clinical correlation. Malignancies can also cause diffuse thickening and enhancement of the CBD.
Pancreatitis is categorised into interstitial and necrotic pancreatitis depending on presence of pancreatic necrosis. Areas of necrosis in necrotising pancreatitis appears as areas of hypoenhancement in comparison to the rest of the pancreas. Later, these form walled off necrosis which appear as heterogeneous collections as opposed to homogenous pseudocysts seen in interstitial pancreatitis.
The patient’s blood test results are listed below
Laboratory investigations
| WCC | 25 x10^9/L |
| Amylase | 2300 U/L |
| Lipase | 2900 U/L |
| Bilirubin | 56 umol/L |
| ALP | 735 U/L |
| GGT | 625 U/L |
| ALT | 195 U/L |
| AST | 340 U/L |
| eGFR | 49 |
Blood cultures subsequently grew Escherichia coli and Klebsiella
CLINICAL CORRELATION
This case demonstrates necrotising gallstone pancreatitis and cholangitis.
By obstructing both the pancreatic ampulla and the common bile duct gallstones can results in combined pancreatitis and cholangitis.
Both necrotising pancreatitis and cholangitis carry significant morbidity and mortality alone, in combination, the mortality is incredibly high.
Surgical management was deemed too high risk for this patient. She was managed instead with percutaneous cholecystostomy, placed under interventional radiology and with broad spectrum antibiotics (ampicillin, gentamicin and metronidazole).
Later, as this patient stabilised, ERCP was offered, however, she opted not for any further interventions.
Her cholecystostomy drain was removed 3 weeks later after a prolonged course of IV antibiotics and she had an amazingly good recovery.
References
- Nickson C. Acute Cholangitis. LITFL
- Hartung MP. Abdominal CT: interstitial pancreatitis. LITFL
- Cadogan M. Murphy’s sign. LITFL
TOP 100 CT SERIES
Provisional fellow in emergency radiology, Liverpool hospital, Sydney. Other areas of interest include paediatric and cardiac imaging.
Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.
Dr Leon Lam FRANZCR MBBS BSci(Med). Clinical Radiologist and Senior Staff Specialist at Liverpool Hospital, Sydney
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).