0:00

Gangrenous cholecystitis.

0:02

It's only about 15% of acute cholecystitis,

0:04

and in these cases, the gallbladder

0:06

has undergone necrosis, or death.

0:09

The risk factors are usually older age groups,

0:11

people with heart disease, and specifically diabetes.

0:14

Diabetes is definitely the biggest risk

0:16

factor for gangrenous cholecystitis.

0:18

These patients probably have less neurofeedback from

0:20

their gallbladder's baseline and are more likely

0:22

to ignore symptomatology and come to our hospital

0:25

later, having already undergone gallbladder necrosis.

0:29

The problem here is that the sonographic

0:31

Murphy sign is often negative, and so

0:33

is the, uh, physical exam Murphy sign.

0:35

So the symptoms are often ambiguous, as

0:37

in our case, where we saw a patient who had

0:40

acute gangrenous cholecystitis on a urogram.

0:43

Frequently, the diagnosis is maybe not

0:45

even suspected by the clinical physicians.

0:48

Unfortunately, the gallbladder's

0:49

undergone, uh, necrosis and death, and it

0:51

also has a pretty high mortality rate.

0:53

Um, these patients can be pretty sick when they're

0:55

presenting, so it is a diagnosis that we need

0:58

to make on ultrasound. Gangrenous cholecystitis

1:00

may demonstrate intraluminal sloughed mucosa.

1:04

You can see that this is actually

1:05

the mucosa of the gallbladder wall.

1:07

It's better to see on the antidependent portion.

1:09

Obviously, anything on the dependent portion

1:11

could just be layering sludge, but you

1:12

can see these nice, beautiful, just layers

1:15

peeling of that gallbladder mucosa.

1:18

We call these intraluminal membranes, or sloughing.

1:20

I like to think of the skin of a snake just

1:24

sloughing off of the, uh, mucosa, and that

1:27

gives me a nice visual of what I may see

1:29

in the setting of acute cholecystitis on

1:32

ultrasound.

1:32

Again, don't expect the sonographic

1:35

Murphy sign to be positive.

1:36

Here, it is probably negative.

1:38

There is no feeling to this gallbladder.

1:39

It is dead.

1:40

It may have been questionable

1:42

even before acute cholecystitis.

1:43

So, in these cases, um, this can be a hard diagnosis,

1:46

and you have to have this at a high level in your

1:49

head when you start seeing this sloughed mucosa.