Medical Image of the Month: Perforated Gangrenous Cholecystitis

Figure 1. A sagittal CT of the abdomen and pelvis without intravenous contrast demonstrates a low-density stone in the neck of the gallbladder (red arrow) along with large amount of complex fluid adjacent to the gallbladder (outlined in green) consistent with a large pericholecystic abscess. A large amount of fat-stranding in the adjacent mesenteric fat is also noted (blue arrow).

Clinical Scenario: A 47-year-old lady with a past medical history of hypertension, DVT on Xarelto, and methamphetamine use presented with a 3-day history of progressive right upper quadrant pain. Physical examination demonstrated marked right upper quadrant tenderness with palpation and significant rebound tenderness. A CT of the abdomen and pelvis without intravenous contrast demonstrated findings consistent with acute calculus cholecystitis with evidence of perforation and a pericholecystic abscess. The patient was taken emergently to the operating room where she underwent an open cholecystectomy which demonstrated perforated gangrenous cholecystitis with a large abscess in the gallbladder fossa. She was admitted to the ICU post-operatively due septic shock and did well with fluid resuscitation and antibiotic administration.

Discussion: Acute cholecystitis is the most common acute complication of cholelithiasis and accounts for 3-9% of hospital admissions for acute abdominal pain. Eight to 95% of cases of acute cholecystitis are the result of a stone obstructing the cystic duct or gallbladder neck. Acute acalculous cholecystitis accounts for the remaining 5-20% of cases of cholecystitis. Ultrasound is the preferred initial examination for patients suspected of having cholecystitis. Gangrenous cholecystitis is the most common complication of acute cholecystitis and often necessitates emergent surgery. Perforated cholecystitis is most commonly seen in association with gangrenous cholecystitis. Perforation most commonly occurs at the gallbladder fundus where blood flow to the gallbladder is most distal.

Lauren Blackley, AG-ACNP-S¹

Madhav Chopra MD²

Tammer El-Aini MD²

¹Grand Canyon University- College of Nursing

²Banner University Medical Center – Main Campus, Department of Pulmonary and Critical Care

Reference

1. Ratanaprasatporn L, Uyeda JW, Wortman JR, Richardson I, Sodickson AD. Multimodality Imaging, including Dual-Energy CT, in the Evaluation of Gallbladder Disease. Radiographics. 2018 Jan-Feb;38(1):75-89. [CrossRef] [PubMed]

Cite as: Blackley L, Chopra M, El-Aini T. Medical Image of the Month: Perforated Gangrenous Cholecystitis. Southwest Journal of Pulmonary and Critical Care. 2021;22(5):100-1. doi: https://doi.org/10.13175/swjpcc010-21 PDF 

Medical Image of the Month: Ludwig’s Angina

Figure 1.  A coronal reconstruction of the patient’s initial post-contrast maxillofacial CT demonstrates swelling of the soft tissues of the floor of the mouth consistent with phlegmonous changes and early abscess formation (blue arrows).  There is also swelling in the region of the vallecula and epiglottis (red arrow).

Figure 2.  A coronal reconstruction of the patient’s follow-up post-contrast maxillofacial CT after placement of a tracheostomy tube demonstrates marked progression of the swelling of the soft tissues of the floor of the mouth with development of a large, ill-defined abscess in the floor of the mouth (blue circle). Note the marked, progressive narrowing of the oropharynx (red arrow) over a period of approximately 24 hours.

Case Presentation: A 65-year-old gentleman with a history of insulin-dependent diabetes mellitus presented to the emergency room with a chief complaint of two days of difficulty swallowing and jaw pain.  Four days prior to presentation, he had extensive dental work performed to address multiple dental caries.  On arrival to the emergency room, he was noted to be tachycardic with difficulty swallowing his saliva and liquids.  On physical examination, he had difficulty opening his mouth with marked swelling of his tongue.  He also had marked swelling of the soft tissues of the floor of the mouth with palpable adenopathy.  A maxillofacial CT with contrast (Figure 1) was performed which demonstrated extensive edema and early abscess formation in the floor of the mouth.  He was initially admitted to the general medicine floor and started on broad-spectrum antibiotics.  Over the course of the next 12 hours, he began to have increased difficulty breathing and was unable to swallow his own secretions.  He was promptly transferred to the ICU where a fiberoptic nasotracheal intubation was attempted at bedside but was unable to be performed given the extensive soft tissue swelling in the posterior oropharynx.  An emergent awake tracheostomy was subsequently performed by ENT.  A repeat maxillofacial CT with contrast (Figure 2) demonstrated marked progression of the inflammatory changes and abscess formation in the floor of the mouth consistent with progressive Ludwig's angina.  The combination of prompt surgical drainage and broad-spectrum antibiotics resulted in marked clinical improvement over the next 72 hours. The patient's final tissue cultures grew Streptococcus viridans.

Ludwig's angina is a potentially life-threatening gangrenous cellulitis of the neck and floor of the mouth which is characterized by progressive submandibular swelling with elevation and posterior displacement of the tongue. Odontogenic infections are the cause for most cases. Pre-existing medical conditions which predispose patients to the development of Ludwig's angina include diabetes mellitus, malnutrition, alcoholism, and immunocompromised states (i.e. AIDS and organ transplantation).

In the early stages of the disease, patients may be managed with observation and intravenous antibiotics to cover for β-hemolytic streptococcus and anaerobic organisms. The most life-threatening complication of Ludwig's angina is airway obstruction.  Immediate involvement of an anesthesiologist and ENT are crucial in the management of this condition.  Blind nasotracheal intubation should not be attempted in these patients given the potential for bleeding and abscess rupture.  Flexible nasotracheal intubation requires skill and experience.  If flexible nasotracheal intubation is not possible, a cricothyrotomy and tracheostomy under local anesthesia can be performed in the emergent setting.  An elective awake tracheostomy is a safer and more logical method of airway management in patients with fully developed Ludwig's angina.

Lauren Estep, MD and Tammer El-Aini, MD

Department of Pulmonary, Critical Care, Allergy and Sleep

University of Arizona College of Medicine

Tucson, AZ USA

References

1. Hasan W, Leonard D, Russell J. Ludwig's Angina-A Controversial Surgical Emergency: How We Do It. Int J Otolaryngol. 2011;2011:231816. [CrossRef] [PubMed]
2. Candamourty R, Venkatachalam S, Babu MR, Kumar GS. Ludwig's Angina - An emergency: A case report with literature review. J Nat Sci Biol Med. 2012 Jul;3(2):206-8. [CrossRef] [PubMed]

Cite as: Estep L, El-Aini T. Medical image of the month: Ludwig’s angina. Southwest J Pulm Crit Care. 2019:18(4):74-5. doi: https://doi.org/10.13175/swjpcc013-19 PDF 

June 2016 Imaging Case of the Month

Michael B. Gotway, MD

Department of Radiology

Mayo Clinic Arizona

Scottsdale, AZ USA

Imaging Case of the Month CME Information  

Members of the Arizona, New Mexico, Colorado and California Thoracic Societies and the Mayo Clinic are able to receive  0.25 AMA PRA Category 1 Credits™. Completion of an evaluation form is required to receive credit and a link is provided on the last panel of the activity.

0.25 AMA PRA Category 1 Credit(s)™

Estimated time to complete this activity: 0.25 hours

Lead Author(s): Michael B. Gotway, MD. All Faculty, CME Planning Committee Members, and the CME Office Reviewers have disclosed that they do not have any relevant financial relationships with commercial interests that would constitute a conflict of interest concerning this CME activity. 

Learning Objectives:
As a result of this activity I will be better able to:    

1. Correctly interpret and identify clinical practices supported by the highest quality available evidence.
2. Will be better able to establsh the optimal evaluation leading to a correct diagnosis for patients with pulmonary, critical care and sleep disorders.
3. Will improve the translation of the most current clinical information into the delivery of high quality care for patients.
4. Will integrate new treatment options in discussing available treatment alternatives for patients with pulmonary, critical care and sleep related disorders.

Learning Format: Case-based, interactive online course, including mandatory assessment questions (number of questions varies by case). Please also read the Technical Requirements.

CME Sponsor: University of Arizona College of Medicine at the Arizona Health Sciences Center.

Current Approval Period: January 1, 2015-December 31, 2016

Financial Support Received: None.

Clinical History: A 65-year-old non-smoking man with a past medical history significant only for dyslipidemia and hypertension presented to the emergency room with a 2-week complaint of intermittent, diffuse, high back pain accompanied by sweating and nausea and non-bloody emesis. The back pain does not radiate. The patient also notes that recently he has suffered from pronounced fatigue and some shortness of breath; until recently he had been an endurance athlete.

Physical Examination: Physical examination was normal; in particular, the back pain was not reproducible on palpation. The patient was afebrile.

Laboratory: Laboratory data were remarkable for a mildly elevated white blood cell count of 11 x 10⁹ cells/L. Serum chemistries were within normal limits and cardiac troponins were negative. Oxygen saturation on room air was 94%.

Radiography: Frontal and lateral chest radiography (Figure 1) was performed.

Figure 1. Frontal (A) and lateral (B) chest radiography

 Which of the following statements regarding the chest radiograph is most accurate? (Click on the correct answer to proceed to the second of eight panels)

1. The frontal chest radiograph shows a large left pleural effusion
2. The frontal chest radiograph shows an abnormally widened mediastinum
3. The frontal chest radiograph shows multifocal consolidation
4. The frontal chest radiograph shows no significant findings
5. The frontal chest radiograph shows numerous small lung nodules

Cite as: Gotway MB. June 2016 imaging case of the month. Southwest J Pulm Crit Care. 2016 Jun;12(6):216-28. doi: http://dx.doi.org/10.13175/swjpcc047-16 PDF