Case Of the Week (COW) 01 Mar 2015
Answer:
DROPPED GALLSTONES.
Findings:
Axial non contrast and contrast enhanced CT images demonstrate minimal low density fluid collection in the right perihepatic space. Two small hyperdense calcifications seen in right perihepatic space consistent with dropped calculi. Laparoscopic surgical clips can be seen in gallbladder fossa.
Discussion:
Laparoscopic cholecystectomy is now the gold standard for the treatment of symptomatic gallstone disease. Although the overall complication rate is less than the traditional open approach, there appear to be at least two operative complications that occur with greater frequency during laparoscopy. One is bile duct injury or bile leakage, and the other appears to be late infection due to dropped gallstones . Most spilled stones remain benign. Abscesses associated with dropped gallstones can present months to years after surgery (reported from 4 months to 10 years after surgery) due to the indolent nature of the inflammatory process associated as well as the variation of abscess location. Stones can lodge in almost any area of the abdomen including the posterior subhepatic space (most common), retroperitoneum inferior to the subhepatic space, Pouch of Douglas, subphrenic space, thorax (empyema), ovary and abdominal wall port sites used during surgery. Bilirubinate stones often contain viable bacteria and are therefore more likely associated with this complication. Imaging findings on CT are varied, including fluid collections with or without calcified gallstones centrally. If diaphragmatic erosion occurs, empyema may be seen. Ultrasonography will show fluid collections as either hypoechoic or mixed echogenicity and possibly echogenic stones with posterior acoustic shadowing. MRI will show signal changes consistent with fluid collections in the expected locations. Low signal intensity foci on T1 images may be seen consistent with gallstones.
Contributed By:
Dr. Geethapriya S
Consultant Radiologist
CSI Kalyani Multispeciality Hospital, Chennai
Answer:
DROPPED GALLSTONES.
Findings:
Axial non contrast and contrast enhanced CT images demonstrate minimal low density fluid collection in the right perihepatic space. Two small hyperdense calcifications seen in right perihepatic space consistent with dropped calculi. Laparoscopic surgical clips can be seen in gallbladder fossa.
Discussion:
Laparoscopic cholecystectomy is now the gold standard for the treatment of symptomatic gallstone disease. Although the overall complication rate is less than the traditional open approach, there appear to be at least two operative complications that occur with greater frequency during laparoscopy. One is bile duct injury or bile leakage, and the other appears to be late infection due to dropped gallstones . Most spilled stones remain benign. Abscesses associated with dropped gallstones can present months to years after surgery (reported from 4 months to 10 years after surgery) due to the indolent nature of the inflammatory process associated as well as the variation of abscess location. Stones can lodge in almost any area of the abdomen including the posterior subhepatic space (most common), retroperitoneum inferior to the subhepatic space, Pouch of Douglas, subphrenic space, thorax (empyema), ovary and abdominal wall port sites used during surgery. Bilirubinate stones often contain viable bacteria and are therefore more likely associated with this complication. Imaging findings on CT are varied, including fluid collections with or without calcified gallstones centrally. If diaphragmatic erosion occurs, empyema may be seen. Ultrasonography will show fluid collections as either hypoechoic or mixed echogenicity and possibly echogenic stones with posterior acoustic shadowing. MRI will show signal changes consistent with fluid collections in the expected locations. Low signal intensity foci on T1 images may be seen consistent with gallstones.
Contributed By:
Dr. Geethapriya S
Consultant Radiologist
CSI Kalyani Multispeciality Hospital, Chennai