[A case of acalculous gangrenous cholecystitis due to artery dissection].

A 62-year-old male presented with right intercostal muscle pain. Clinical examination revealed muscular defense in the same area. Abdominal ultrasonography revealed a distended gallbladder and ascites effusion, but no gallstones or polyps were present. Contrast-enhanced computerized tomography was performed, which revealed luminal obstruction due to arterial dissection of the celiac artery and intrinsic hepatic artery. This finding suggested gangrenous cholecystitis; thus, urgent cholecystectomy was performed. Only a few cases of celiac artery dissection and only one case of gangrenous cholecystitis without stones have been reported. We report here an extremely rare case of celiac artery dissection.

Prediction of extensive necrotic change in acute gangrenous cholecystitis.

PURPOSE: Gangrenous cholecystitis (GC) is a severe type of acute cholecystitis that implies higher mortality and morbidity rates than uncomplicated cholecystitis. The characteristics of GC are various for each case. However, preoperative predictors of GC with extensive necrotic change have not been investigated well. METHODS: A total of 239 patients who were pathologically diagnosed with GC underwent laparoscopic cholecystectomy at our hospital between January 2013 and December 2021. Of these, 135 patients were included in this study and were subdivided into the extensive necrosis group (patients with necrotic change extending to the neck of the gallbladder, n = 18) and the control group (patients with necrotic change limited to the fundus or body, not extending to the neck, n = 117) according to each operation video. Patient characteristics and perioperative factors predicting extensive necrotic change were investigated. RESULTS: Pericholecystic fat stranding (83.3 vs. 53.8%, p = 0.018) and absence of wall enhancement on preoperative CT images (50.0 vs. 24.7%, p = 0.026) were significantly associated with extensive necrosis. Seven of 18 patients in the extensive necrosis group showed necrotic changes beyond the infundibulum. The absence of wall enhancement on preoperative CT images (71.4 vs. 28.8%, p = 0.018) was significantly associated with necrotic changes beyond the infundibulum. CONCLUSIONS: Pericholecystic fat stranding and absence of wall enhancement on preoperative enhanced CT are predictors of extensive necrotic change in patients with GC. In addition, the absence of wall enhancement also predicts the presence of necrotic changes beyond the infundibulum.

An internal hernia caused by Meckel's diverticulum: a case report.

BACKGROUND: Meckel's diverticulum is a remnant of the omphalomesenteric duct. It can lead to intestinal perforation, obstruction and gastrointestinal bleeding. While the internal hernia caused by Meckel's diverticulum is rarely reported. CASE PRESENTATION: We report a case of a 45-year old female patient who presented with intestinal obstruction and on laparotomy was found to have Meckel's diverticulum with internal hernia causing intestinal gangrene. Segmental bowel resection was performed and the patient had uneventful recovery. CONCLUSIONS: In patients with acute intestinal obstruction without previous abdominal surgery, Meckel's diverticulum and its complications should be suspected.

B-Mode Ultrasound Findings in a Patient With Suspected Pulmonary Gangrene.

OBJECTIVES: Lung ultrasound has shown increasing diagnostic value in many lung diseases and has become an efficient tool in the management of dyspnea. In the present case report, we describe a new ultrasound feature of potential interest. DATA SOURCES: Clinical observation of a patient. STUDY SELECTION: Case report. DATA EXTRACTION: Data were extracted from medical records, after obtaining consent from the patient's family. Illustrations were extracted from the imaging software and a video device. DATA SYNTHESIS: A 56-year-old man was admitted with pneumonia of adverse outcome. Lung ultrasound, a method increasingly considered as a bedside gold standard in critically ill patients due to its overwhelming advantages, was the only tool able to specify the lung injuries. We describe herein a distinctive sign unequivocally evoking a destructive process suggestive of pulmonary gangrene, a variant of the fractal sign combining a lung consolidation with an underlying heterogeneous free fluid. CONCLUSIONS: Lung ultrasound may help highlight pulmonary gangrene, a poorly-known disease, with this new ultrasonographic description. The next step will be to ascertain the relation between this new ultrasound feature and pulmonary gangrene and to assess how this bedside diagnosis could impact the prognosis of the disease.

Dual-Energy CT in Differentiating Nonperforated Gangrenous Appendicitis From Uncomplicated Appendicitis.

OBJECTIVE: The hypothesis of this study was that the use of dual-energy spectral techniques in CT can improve accuracy in the diagnosis of acute gangrenous appendicitis. MATERIALS AND METHODS: This retrospective study included 209 patients with a pathologic diagnosis of appendicitis. Two board-certified abdominal radiologists reviewed 120-kV simulated images, 40-keV virtual monoenergetic images, and color-coded iodine overlay images. Sensitivity, specificity, positive and negative predictive values (PPV and NPV), accuracy, and interobserver agreement were calculated for each set of images. RESULTS: Forty-four patients (21.0%) had histopathologic results positive for gangrenous appendicitis. The sensitivity of 40-kV virtual monoenergetic imaging was 100% (44/44); specificity, 81.2% (134/165); PPV, 58.7% (44/75); NPV, 100% (134/134); accuracy, 85.2%; and interobserver agreement, 0.99. The corresponding values for the iodine overlay imaging datasets were 100% (44/44), 80.0% (132/165), 57.1% (44/77), 100% (132/132), 84.2%, and 0.99 and for 120-kV simulated imaging were 22.7% (10/44), 96.4% (159/165), 62.5% (10/16), 82.4% (159/193), 77.5%, and 0.93. All cases of gangrenous appendicitis had true-positive results of virtual monoenergetic and iodine overlay imaging. There were no false-negative results of virtual monoenergetic or iodine overlay imaging. CONCLUSION: In cases of suspected appendicitis, dual-energy CT that includes virtual monoenergetic and iodine overlay imaging is accurate for confirming and excluding the presence of gangrenous appendicitis with high sensitivity and specificity.

Infectious and Non-Infectious Diseases Causing the Air Crescent Sign: A State-of-the-Art Review.

Aspergilloma, also known as mycetoma or fungus ball, is characterized by a round or oval mass with soft-tissue attenuation within a preexisting lung cavity. The typical computed tomography (CT) aspect of an aspergilloma is a mass separated from the wall of the cavity by an airspace of variable size and shape, resulting in the air crescent sign, also known as the meniscus sign. This CT feature is non-specific and can be simulated by several other entities that result in intracavitary masses. This review describes the main clinical and imaging aspects of the infectious and non-infectious diseases that may present with fungus-ball appearance, including pulmonary hydatid cyst, Rasmussen aneurysm, pulmonary gangrene, intracavitary clot, textiloma, lung cancer, metastasis, and teratoma, focusing on the differential diagnosis.

Hemorrhage and intestinal obstruction secondary to a Meckel's diverticulum: a case report.

We present one case of a 17-year-old male with ten-year history of anemia complaining of recurrent bloody stools, abdominal pain and fatigue for 3 months.The gastroscopy, colonoscopy, the-first-time double-balloon enteroscopy (DBE) through the anus and capsule endoscopy were performed with negative results. 99mTc-pertechnetate scan showed a round-like high radioactive concentration at the ileocecum. Double-balloon enteroscopy through the anus was performed again by a more-experienced endoscopic physician, the diverticulum was found at a distance of 50 cm to the ileocecal valve. Then a laparotomy was performed.

The possibility of free tissue transfer as a nutrient flap for critical ischemic foot: A case report.

Microsurgical procedure of free tissue transfer in critical limb ischemia patients with large ulceration has already been established. The nutrient flap concept was that transferred tissue functioned not only to cover the skin defect but also as a supplementary blood supply to the ischemic lower leg. This report showed the justification for this concept, which was rarely discussed. A 58-year-old male patient with progressive forefoot gangrene caused by arteriosclerosis obliterans was presented. The distal bypass procedure was performed as revascularization surgery, and a latissimus dorsi (LD) myocutaneous flap was transplanted to cover ulceration. The arterial pedicle of the flap was anastomosed to the vein graft in an end-to-end manner, and the venous pedicle was anastomosed to the posterior tibialis vein in an end-to-end manner. Bypass graft blood flow went straight to the LD flap only. The postoperative course was uneventful. The free flap and right foot survived successfully and the patient was ambulatory with no recurrence of ulceration wearing order-made shoes more than three years after transplantation. Vessel-selective angiography was performed two months after surgery. An angiographic catheter was inserted into the bypass graft, which ran straight through the flap nutrient artery. The results obtained showed that not only the transferred flap area, but also the remaining original foot soft tissue (including the sole and heel) was clearly visualized radiologically only through the flap nutrient vessel. This findings of the angiography appear to provide direct evidence for the nutrient flap concept.

Gallstone ileus presenting as obstructive gangrenous appendicitis.

We present the very unusual case of a 38-year-old woman with acute appendicitis and intestinal obstruction. During surgery, a 2.5 cm gallstone impacted at the base of the cecal appendix was found as the cause of a gangrenous appendicitis and obstruction; a choledochal-duodenal fistula was found during the same surgery with no gallstones remaining in the gallbladder or elsewhere. The case was managed by appendectomy with retrieval of the gallstones and no other procedure was performed for the gallbladder or the fistula, since no other gallstone was found on examination. Previously, she was found to have a round, radio-opaque image on the right iliac fossa on imaging, initially identified as an appendicolith, but after pathological examination it turned out to contain cholesterol and calcium bilirubinate. Gallstone ileus as the cause of an obstructive gangrenous appendicitis is a very unusual disease presentation that should be kept in mind when finding an unusual appendicolith presentation in or out the appendix.

CT Findings for Detecting the Presence of Gangrenous Ischemia in Cholecystitis.

OBJECTIVE: The objective of our study was to evaluate the diagnostic accuracy of CT in differentiating gangrenous cholecystitis from uncomplicated cholecystitis and healthy gallbladders. MATERIALS AND METHODS: We performed a retrospective review of 308 patients with histologically proven gangrenous cholecystitis who underwent preoperative CT 1 month before gallbladder removal over a 4-year period. Two readers who were blinded to the histologic diagnosis independently recorded CT features of and overall likelihood of gangrenous cholecystitis on a 5-point scale (1, definitely absent; 5, definitely present). Ratings were dichotomized such that a diagnosis was considered present at a rating of 4 or 5 and considered absent at lower ratings. Interobserver variability for individual CT findings was also assessed. RESULTS: Patients had gangrenous cholecystitis (n = 28), acute cholecystitis (n = 98), chronic cholecystitis (n = 118), or healthy gallbladders (n = 64). Multivariate analysis showed that CT findings of gallbladder distention greater than 4.0 cm (odds ratio [OR], 9.63; p < 0.01), mural striation (OR, 11.39; p < 0.01), and decreased mural enhancement (OR, 3.55; p < 0.05) independently predicted gangrenous cholecystitis. Using these CT features, the diagnosis of gangrenous cholecystitis was made with a specificity of 93.9% and 89.6% for readers 1 and 2, respectively, and accuracy of 90.9% and 87.0%, respectively. Good agreement was seen between the two readers with respect to gallbladder distention greater than 4.0 cm (κ = 0.77) and decreased mural enhancement (κ = 0.64). CONCLUSION: A markedly distended gallbladder associated with decreased wall enhancement is highly specific for gangrenous cholecystitis.

Use of dynamic CT attenuation value for diagnosis of acute gangrenous cholecystitis.

OBJECTIVE: To determine if the increase in transient focal enhancement of the liver adjacent to the gallbladder seen on dynamic computed tomography (CT) is greater in gangrenous cholecystitis than in nongangrenous cholecystitis by determining the CT attenuation value. METHODS: We retrospectively reviewed the medical records of 57 patients who underwent emergency cholecystectomy for acute cholecystitis and preoperative dynamic CT scans between March 2011 and April 2016. Based on the pathology findings, patients were assigned to a gangrenous group or a nongangrenous group. The CT attenuation ratio (AR) was defined as the ratio of the maximum CT attenuation value in the region of interest in segment 5 (liver parenchyma adjacent to the gallbladder) and that in the control region of interest in segment 8. The patient characteristics and CT findings were compared between the groups. The appropriate AR of the arterial phase (ARAP) cutoff value for a diagnosis of gangrenous cholecystitis was determined using receiver operating characteristic curve analysis. RESULTS: The ARAP was significantly higher in the gangrenous group than in the nongangrenous group (P < .001); the area under the receiver operating characteristic curve was 0.849. The ARAP cutoff value of 1.46 had a sensitivity and specificity of 84.6% and 83.9%, respectively (odds ratio, 21.17; 95% confidence interval, 4.90-118.91), and ARAP ≥1.46 was significantly correlated with a diagnosis of gangrenous cholecystitis (P < .001). CONCLUSIONS: The increase in transient focal enhancement of the liver adjacent to the gallbladder during the arterial phase of dynamic CT was greater in gangrenous cholecystitis than in nongangrenous cholecystitis.

Acute Gallbladder Torsion with Gangrene and Cholelithiasis ­ A Rare Condition

We report a case of a 75-year-old female with acute torsion of the gallbladder with gangrene and cholelithiasis. On admission, the patient underwent physical examination, laboratory blood analysis, abdominal ultrasound and plain abdominal x-ray. Due to the signs of acute abdomen and poor general condition of the patient, urgent surgical procedure was indicated. Intraoperatively, the gallbladder was found to be greatly enlarged, gangrenous and greatly distended with 360° clockwise torsion around its mesentery. Cholecystectomy was performed. Gallbladder torsion is a rare surgical emergency which physicians should bear in mind when encountering patients with symptoms of acute cholecystitis. The only treatment for this condition is urgent cholecystectomy with prior detorsion. The mortality rate in patients not undergoing surgery is 100%.

BWH emergency radiology-surgical correlation: torsion of Meckel's diverticulum.

We present the radiologic findings and intraoperative correlation of a torsed Meckel's diverticulum leading to small-bowel obstruction in a 65-year-old male without prior abdominal surgery. As this is a rare entity and difficult to diagnose, an understanding of the clinical presentation and radiologic findings correlated with this pathology can help to expedite diagnosis and treatment.

Preoperative diagnosis of gangrenous acute cholecystitis: usefulness of CEUS.

PURPOSE: To evaluate CEUS for the preoperative diagnosis of gangrenous acute cholecystitis. SUBJECTS AND METHODS: This prospective study was approved by our institution's ethical committee. Fifty-six patients who underwent both US and CEUS and were confirmed as presenting with acute cholecystitis at pathology were included. Clinical data, mean time until surgery, macroscopic appearance of the GB, and the presence of gangrene at pathology were noted. Baseline US images and CEUS cine clips were analyzed by two experienced radiologists. Statistical analyses were performed. RESULTS: Gangrenous acute cholecystitis was diagnosed in 23 (41%) patients and uncomplicated acute cholecystitis in 33 (59%). Patients with gangrenous acute cholecystitis were found to be older (p = 0.048). Mean time from CEUS to surgery was found to be shorter in patients presenting with gangrenous acute cholecystitis (p = 0.052). At US, GB short axis ≥4 cm (p = 0.039) and GB wall interruption (p = 0.037) showed a statistically significant association with the diagnosis of gangrenous acute cholecystitis. On CEUS, discontinuous or irregular GB wall enhancement was reported in 19/23 (83%) patients with gangrenous acute cholecystitis and showed association with the presence of gangrene at pathology (p = 0.001). The interobserver agreement for the presence of discontinuous or irregular GB wall enhancement on CEUS images was good. CONCLUSION: Performing CEUS on patients presenting with US findings of acute cholecystitis is relevant, since the presence of a discontinuous or irregular enhancement of the GB wall appears to be correlated with the diagnosis of gangrenous acute cholecystitis.

Acute cholecystitis: do sonographic findings and WBC count predict gangrenous changes?

OBJECTIVE: The purpose of our study was to determine, first, if gallbladder wall striations in patients with sonographic findings suspicious for acute cholecystitis are associated with gangrenous changes and certain histologic features; and, second, if WBC count or other sonographic findings are associated with gangrenous cholecystitis. MATERIALS AND METHODS: Sixty-eight patients who underwent cholecystectomies within 48 hours of sonography comprised the study group. Sonograms and reports were reviewed for wall thickness, striations, Murphy sign, pericholecystic fluid, wall irregularity, intraluminal membranes, and luminal short-axis diameter. Medical records were reviewed for WBC count and pathology reports for the diagnosis. Histologic specimens were reviewed for pathologic changes. Statistical analyses tested for associations between nongangrenous and gangrenous cholecystitis and sonographic findings and for associations between wall striations and histologic features. RESULTS: Ten patients had gangrenous cholecystitis and 57, nongangrenous cholecystitis. One had cholesterolosis. Thirty patients had wall striations: 60% had gangrenous and 42% nongangrenous cholecystitis. There was no association with the pathology diagnosis (p = 0.32). There was no association between any histologic feature and wall striations (p ≥ 0.19). A Murphy sign was reported in 70% of patients with gangrenous cholecystitis and in 82% with nongangrenous cholecystitis; there was no association with the pathology diagnosis (p = 0.39). Wall thickness and WBC count were greater in patients with gangrenous cholecystitis than in those with nongangrenous cholecystitis (p ≤ 0.04). CONCLUSION: Gallbladder wall thickening and increased WBC counts were associated with gangrenous cholecystitis; however, there was considerable overlap between the two groups. Wall striations and a negative Murphy sign were not associated with gangrenous cholecystitis.