Answer for BIR CoW 08 Aug 2021
Acute emphysematous pancreatitis / Choledocholithiasis / Acute calculous cholecystitis with gangrene
Findings
Multiple calculi (8-10) in Gall bladder. Wall thickness of GB- 9mm Irregular asymmetric areas in body of GB; pericholecystic fluid collection and fat stranding. Multiple calculi noted in CBD largest measuring 1.3 cm in proximal CBD. Calculus of size 1.2cm at ampulla. Head and body of pancreas not visualised; collection with air pockets noted in anterior pararenal space replacing head and body of pancreas. Tail of pancreas appears edematous. Extensive peripancreatic fat stranding noted. Collection of size 2.8 x 5cm noted in splenic recess of lesser sac. CBD stent in situ. IHBR – normal CBD diameter – 1.5cm ; MPD – 0.6cm ; RHD- 0.9cm ; LHD- 0.98cm ; CHD- 0.95cm. Intra-operative findings: Gall bladder perforation / Infected pancreatic necrosis with lesser sac necrotic collection/ choledocholithiasis/ transverse colon perforation with necrosis of mesocolon s/p ERCP CBD stenting. Procedure done : Cholecystectomy / CBD exploration and stone removal with primary closure / pancreatic necrosectomy with drainage / segmental resection of transverse colon/ loop ileostomy.
Discussion
Emphysematous pancreatitis: The most common causes of acute pancreatitis are the passage of gallstones and alcohol abuse. An overall mortality rate of 4% rapidly escalates to more than 50% when complications (eg, abscess formation, superinfection with gas-forming bacteria) occur. The infecting organisms are usually coliform bacteria and may reach the pancreatic bed by way of the bloodstream or lymphatic channels, a fistula from adjacent bowel, transmural passage from the transverse colon, or reflux of enteric organisms into the pancreatic duct or biliary tree via a patulous ampulla of Vater . Gas may be detected in up to 22% of pancreatic abscesses; however, its presence alone is not specific for the diagnosis of infection. Other sources of intraductal or parenchymal pancreatic gas include reflux from the duodenum following sphincterotomy, endoscopic instrumentation, enteric fistula (commonly involving the transverse colon), and end-organ infarction. Patients with emphysematous pancreatitis are usually debilitated and often have underlying immunocompromised conditions such as poorly controlled diabetes or chronic renal failure. Early radiographic detection of retroperitoneal gas is critical in the evaluation of superimposed emphysematous infection of the pancreas. Conventional abdominal radiography may demonstrate mottled gas overlying the midabdomen .This finding is not specific for pancreatitis because abscess involving the lesser sac or perinephric space may also have this appearance CT is the modality of choice for detecting parenchymal gas as well as evaluating its extent and location. Fluid collections or portal venous air is readily identified, and, although intravenously administered contrast material is not necessary for the visualization of air, it is useful for evaluating potential complications including parenchymal necrosis and abscess formation. The prognosis for emphysematous pancreatitis is grave, and successful treatment requires aggressive management of the infection with systemic antimicrobial therapy and control of septic shock. Early surgical debridement or percutaneous drainage is usually performed, and recovery is typically prolonged.
Gangrenous cholecystitis: Increased intraluminal pressure may produce gallbladder wall ischemia and ultimately necrosis, resulting in gangrenous cholecystitis. It complicates acute cholecystitis in 2%–38% of cases . Perforation is more common than in uncomplicated cholecystitis, leading to increased morbidity and mortality. As the gallbladder necroses, clinical symptoms and signs may become more generalized. The abdominal pain may be diffuse in up to 50% of patients possibly because of more generalized peritonitis with inflammation of the parietal peritoneum. In the symptomatic patient, the presence of asymmetric gallbladder wall thickening or intraluminal membranes should be viewed with suspicion for gangrenous change . The sonographic Murphy sign may be negative in up to 66% of cases, probably because of denervation of the gallbladder wall by gangrenous changes. At CT, findings with the highest specificity for gangrenous cholecystitis are gas in the wall or lumen , intraluminal membranes (99.5%), irregular or absent wall (97.6%), and abscess (96.6%). Because of the increased risk of perforation (up to 10%) , early cholecystectomy should be performed if gangrenous cholecystitis is likely. References: De Lange EE, Slutsky VS, Swanson S, Shaffer HA Jr. Computed tomography of emphysematous gastritis. J Comput Assist Tomogr ; 10:139– 141. Mendez G Jr, Isikoff MB. Significance of intrapancreatic gas demonstrated by CT: a review of nine cases. AJR Am J Roentgenol; 132:59–62. Hegner CF. Gaseous pericholecystitis with cholecystitis and cholelithiasis. Arch Surg ; 22: 993–1000. McMillin K. Computed tomography of emphysematous cholecystitis. J Comput Assist Tomogr 1985; 9:330–332. Daly JJ Jr, Alderman DF, Conway WF. General case of the day. RadioGraphics 95; 15:489– 492.
Findings
Multiple calculi (8-10) in Gall bladder. Wall thickness of GB- 9mm Irregular asymmetric areas in body of GB; pericholecystic fluid collection and fat stranding. Multiple calculi noted in CBD largest measuring 1.3 cm in proximal CBD. Calculus of size 1.2cm at ampulla. Head and body of pancreas not visualised; collection with air pockets noted in anterior pararenal space replacing head and body of pancreas. Tail of pancreas appears edematous. Extensive peripancreatic fat stranding noted. Collection of size 2.8 x 5cm noted in splenic recess of lesser sac. CBD stent in situ. IHBR – normal CBD diameter – 1.5cm ; MPD – 0.6cm ; RHD- 0.9cm ; LHD- 0.98cm ; CHD- 0.95cm. Intra-operative findings: Gall bladder perforation / Infected pancreatic necrosis with lesser sac necrotic collection/ choledocholithiasis/ transverse colon perforation with necrosis of mesocolon s/p ERCP CBD stenting. Procedure done : Cholecystectomy / CBD exploration and stone removal with primary closure / pancreatic necrosectomy with drainage / segmental resection of transverse colon/ loop ileostomy.
Discussion
Emphysematous pancreatitis: The most common causes of acute pancreatitis are the passage of gallstones and alcohol abuse. An overall mortality rate of 4% rapidly escalates to more than 50% when complications (eg, abscess formation, superinfection with gas-forming bacteria) occur. The infecting organisms are usually coliform bacteria and may reach the pancreatic bed by way of the bloodstream or lymphatic channels, a fistula from adjacent bowel, transmural passage from the transverse colon, or reflux of enteric organisms into the pancreatic duct or biliary tree via a patulous ampulla of Vater . Gas may be detected in up to 22% of pancreatic abscesses; however, its presence alone is not specific for the diagnosis of infection. Other sources of intraductal or parenchymal pancreatic gas include reflux from the duodenum following sphincterotomy, endoscopic instrumentation, enteric fistula (commonly involving the transverse colon), and end-organ infarction. Patients with emphysematous pancreatitis are usually debilitated and often have underlying immunocompromised conditions such as poorly controlled diabetes or chronic renal failure. Early radiographic detection of retroperitoneal gas is critical in the evaluation of superimposed emphysematous infection of the pancreas. Conventional abdominal radiography may demonstrate mottled gas overlying the midabdomen .This finding is not specific for pancreatitis because abscess involving the lesser sac or perinephric space may also have this appearance CT is the modality of choice for detecting parenchymal gas as well as evaluating its extent and location. Fluid collections or portal venous air is readily identified, and, although intravenously administered contrast material is not necessary for the visualization of air, it is useful for evaluating potential complications including parenchymal necrosis and abscess formation. The prognosis for emphysematous pancreatitis is grave, and successful treatment requires aggressive management of the infection with systemic antimicrobial therapy and control of septic shock. Early surgical debridement or percutaneous drainage is usually performed, and recovery is typically prolonged.
Gangrenous cholecystitis: Increased intraluminal pressure may produce gallbladder wall ischemia and ultimately necrosis, resulting in gangrenous cholecystitis. It complicates acute cholecystitis in 2%–38% of cases . Perforation is more common than in uncomplicated cholecystitis, leading to increased morbidity and mortality. As the gallbladder necroses, clinical symptoms and signs may become more generalized. The abdominal pain may be diffuse in up to 50% of patients possibly because of more generalized peritonitis with inflammation of the parietal peritoneum. In the symptomatic patient, the presence of asymmetric gallbladder wall thickening or intraluminal membranes should be viewed with suspicion for gangrenous change . The sonographic Murphy sign may be negative in up to 66% of cases, probably because of denervation of the gallbladder wall by gangrenous changes. At CT, findings with the highest specificity for gangrenous cholecystitis are gas in the wall or lumen , intraluminal membranes (99.5%), irregular or absent wall (97.6%), and abscess (96.6%). Because of the increased risk of perforation (up to 10%) , early cholecystectomy should be performed if gangrenous cholecystitis is likely. References: De Lange EE, Slutsky VS, Swanson S, Shaffer HA Jr. Computed tomography of emphysematous gastritis. J Comput Assist Tomogr ; 10:139– 141. Mendez G Jr, Isikoff MB. Significance of intrapancreatic gas demonstrated by CT: a review of nine cases. AJR Am J Roentgenol; 132:59–62. Hegner CF. Gaseous pericholecystitis with cholecystitis and cholelithiasis. Arch Surg ; 22: 993–1000. McMillin K. Computed tomography of emphysematous cholecystitis. J Comput Assist Tomogr 1985; 9:330–332. Daly JJ Jr, Alderman DF, Conway WF. General case of the day. RadioGraphics 95; 15:489– 492.
Note:
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!
We do not discourage differential diagnosis. But all the differentials must satisfy the findings noted in the case.
If you feel you have answered rightly but cannot find your name in the above list, please call 09551942599.
Did you Know?
The order in which the names appear in this winner's list is based on the time of submission. The first person to send the correct answer gets his/her name on top of the list!