An 83 year old diet controlled diabetic if brought in by his family with fevers and confusion. He had complained of some mild abdominal discomfort 48 hours before.
On examination he is delirious; in rapid atrial fibrillation; blood pressure 92/55; and lactate of 4.6. His other blood test results are pending.
As part of the search for a source of infection you scan his gallbladder.
Describe and interpret these scans
Image 1 & 2: The gallbladder.
The gallbladder is distended and contains layering sludge and stones. There is gas within the lumen of the GB and also within the thickened GB wall. The gas has risen to the gallbladder fundus – the most apical part in the supine patient. Here it appears bright and casts a dirty shadow.
Looking beyond the gallbladder there is also free gas and layering collection in the pericholecystic tissues.
Gas locules are bright and cast a dirty acoustic shadow. Where gas is more extensive than this case an emphysematous gallbladder can have the appearance of gas filled bowel and is easily missed.
I always include biliary ultrasound in my search for a focus of infection in undifferentiated sepsis, particularly in the elderly patient unable to give a good history.