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Beyond acute cholecystitis—gallstone-related complications and what the emergency radiologist should know

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Abstract

The purpose of this study is to emphasize the imaging features of complications of gallstones beyond the cystic duct on ultrasound (US), enhanced and nonenhanced computed tomography (CECT and NECT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), and endoscopic retrograde cholangiopancreatography (ERCP). This article includes a brief overview of gallstone imaging and emerging trends in the detection of gallstones. This review article will highlight complications of gallstones, including choledocholithiasis, gallstone pancreatitis, acute cholangitis, Mirizzi syndrome, cholecystobiliary and cholecystoenteric fistulas, and gallstone ileus. Imaging findings and limitations of US, CT, MRI, and ERCP will be discussed. The review article will also briefly discuss the management of each disease. The presence of gallstones beyond the level of the cystic duct can lead to a spectrum of diseases, and emergency radiologists play a critical role in disease management by providing a timely diagnosis. Documenting the location of a gallstone within the common bile duct (CBD) in symptomatic cholelithiasis and the presence of acute interstitial edematous pancreatitis and/or ascending cholangitis plays a pivotal role in disease management. Establishing the presence of ectopic gallstones and biliary-enteric fistulae has a significant role in directing patient management.

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References

  1. Zimmer V, Lammert F (2015) Acute bacterial cholangitis. Viszeralmedizin 31(3):166–172. https://doi.org/10.1159/000430965

    Article  PubMed  PubMed Central  Google Scholar 

  2. Chang L et al (2018) Clinical and radiological diagnosis of gallstone ileus: a mini review. Emerg Radiol 25(2):189–196. https://doi.org/10.1007/s10140-017-1568-5

    Article  PubMed  Google Scholar 

  3. Kratzer W, Mason RA, Kächele V (1999) Prevalence of gallstones in sonographic surveys worldwide. J Clin Ultrasound 27(1):1–7

    Article  CAS  Google Scholar 

  4. Sakorafas GH, Milingos D, Peros G (2007) Asymptomatic cholelithiasis: is cholecystectomy really needed? A critical reappraisal 15 years after the introduction of laparoscopic cholecystectomy. Dig Dis Sci 52(5):1313–1325

    Article  Google Scholar 

  5. Gracie WA, Ransohoff DF (1982) The natural history of silent gallstones: the innocent gallstone is not a myth. N Engl J Med 307(13):798–800

    Article  CAS  Google Scholar 

  6. Ruhl CE, Everhart JE (2011) Gallstone disease is associated with increased mortality in the United States. Gastroenterology 140(2):508–516

    Article  Google Scholar 

  7. McIntosh DM, Penney HF (1980) Gray-scale ultrasonography as a screening procedure in the detection of gallbladder disease. Radiology 136(3):725–727. https://doi.org/10.1148/radiology.136.3.7403554

    Article  CAS  PubMed  Google Scholar 

  8. Bortoff GA et al (2000) Gallbladder stones: imaging and intervention. Radiographics 20(3):751–766. https://doi.org/10.1148/radiographics.20.3.g00ma16751

    Article  CAS  PubMed  Google Scholar 

  9. MacDonald FR, Cooperberg PL, Cohen MM (1981) The WES triad — a specific sonographic sign of gallstones in the contracted gallbladder. Gastrointest Radiol 6(1):39–41. https://doi.org/10.1007/BF01890219

    Article  CAS  PubMed  Google Scholar 

  10. Ratanaprasatporn L et al (2018) Multimodality imaging, including dual-energy CT, in the evaluation of gallbladder disease. Radiographics 38(1):75–89. https://doi.org/10.1148/rg.2018170076

    Article  PubMed  Google Scholar 

  11. Patel NB, Oto A, Thomas S (2013) Multidetector CT of emergent biliary pathologic conditions. Radiographics 33(7):1867–1888. https://doi.org/10.1148/rg.337125038

    Article  PubMed  Google Scholar 

  12. Gore RM et al (2010) Gallbladder imaging. Gastroenterol Clin North Am 39(2):265–287. https://doi.org/10.1016/j.gtc.2010.02.009

    Article  PubMed  Google Scholar 

  13. Uyeda JW, Richardson IJ, Sodickson AD (2017) Making the invisible visible: improving conspicuity of noncalcified gallstones using dual-energy CT. Abdom Radiol (NY) 42(12):2933–2939. https://doi.org/10.1007/s00261-017-1229-x

    Article  Google Scholar 

  14. Yang CB et al (2017) Clinical application of dual-energy spectral computed tomography in detecting cholesterol gallstones from surrounding bile. Acad Radiol 24(4):478–482. https://doi.org/10.1016/j.acra.2016.10.006

    Article  PubMed  Google Scholar 

  15. Bae JS et al. (2019) Utilization of virtual non-contrast images derived from dual-energy CT in evaluation of biliary stone disease: virtual non-contrast image can replace true non-contrast image regarding biliary stone detection. Eur J Radiol 116: 34–40. https://www.sciencedirect.com/science/article/pii/S0720048X19301408. Accessed 2 Nov 2021

  16. Murphy MC et al (2020) Gallstones top to toe: what the radiologist needs to know. Insights Imaging 11(1):13. https://doi.org/10.1186/s13244-019-0825-4

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Mendler MH et al (1998) Value of MR cholangiography in the diagnosis of obstructive diseases of the biliary tree: a study of 58 cases. Am J Gastroenterol 93(12):2482–2490

    Article  CAS  Google Scholar 

  18. Gutt C, Schläfer S, Lammert F (2020) The treatment of gallstone disease. Dtsch Arztebl Int 117(9):148–158

    PubMed  PubMed Central  Google Scholar 

  19. Tazuma S (2006) Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Pract Res Clin Gastroenterol 20(6):1075–1083. https://doi.org/10.1016/j.bpg.2006.05.009

    Article  PubMed  Google Scholar 

  20. Perveze Z, Krishnamurthy C, Duckworth CW (2008) The incidence of choledocholithiasis in a community setting. Gastrointest Endosc 67(5):AB297. https://doi.org/10.1016/j.gie.2008.03.863

    Article  Google Scholar 

  21. Dasari BV et al (2013) Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 12:CD003327. https://doi.org/10.1002/14651858.cd003327.pub4

    Article  Google Scholar 

  22. Molvar C, Glaenzer B (2016) Choledocholithiasis: evaluation, treatment, and outcomes. Semin Intervent Radiol 33(4):268–276

    Article  Google Scholar 

  23. Condon FJ (2019) Choledocholithiasis and cholangitis: incidence, initial management, and surgical management. In: Lim R (ed) Multidisciplinary approaches to common surgical problems. Springer International Publishing, Cham, pp 161–166

    Chapter  Google Scholar 

  24. Abraham S et al (2014) Surgical and nonsurgical management of gallstones. Am Fam Physician 89(10):795–802

    PubMed  Google Scholar 

  25. Perret RS, Sloop GD, Borne JA (2000) Common bile duct measurements in an elderly population. J Ultrasound Med 19(11):727–730. https://doi.org/10.7863/jum.2000.19.11.727

    Article  CAS  PubMed  Google Scholar 

  26. Einstein DM et al (1984) The insensitivity of sonography in the detection of choledocholithiasis. Am J Roentgenol 142(4):725–728. https://doi.org/10.2214/ajr.142.4.725

    Article  CAS  Google Scholar 

  27. Veronica B et al (2019) Imaging of biliary colic and cholecystitis. In: Cova MA, Stacul F (eds) Pain imaging: a clinical-radiological approach to pain diagnosis. Springer International Publishing, Cham, pp 229–245

    Chapter  Google Scholar 

  28. Wertz JR et al (2018) Comparing the diagnostic accuracy of ultrasound and CT in evaluating acute cholecystitis. AJR Am J Roentgenol 211(2):W92-w97

    Article  Google Scholar 

  29. Anderson SW et al (2006) Accuracy of MDCT in the diagnosis of choledocholithiasis. Am J Roentgenol 187(1):174–180. https://doi.org/10.2214/AJR.05.0459

    Article  Google Scholar 

  30. Verma D et al (2006) EUS vs MRCP for detection of choledocholithiasis. Gastrointest Endosc 64(2):248–254

    Article  Google Scholar 

  31. Makmun D, Fauzi A, Shatri H (2017) Sensitivity and specificity of magnetic resonance cholangiopancreatography versus endoscopic ultrasonography against endoscopic retrograde cholangiopancreatography in diagnosing choledocholithiasis: the Indonesian experience. Clin Endosc 50(5):486–490

    Article  Google Scholar 

  32. Gurusamy KS et al (2015) Endoscopic retrograde cholangiopancreatography versus intraoperative cholangiography for diagnosis of common bile duct stones. Cochrane Database Syst Rev 2015(2):Cd010339

    PubMed Central  Google Scholar 

  33. Kint JF et al (2015) Percutaneous treatment of common bile duct stones: results and complications in 110 consecutive patients. Dig Surg 32(1):9–15

    Article  CAS  Google Scholar 

  34. Jung GS et al (2019) Percutaneous transcholecystic removal of common bile duct stones: case series in 114 patients. Radiology 290(1):238–243

    Article  Google Scholar 

  35. Pereira J et al (2017) Accuracy of ultrasound in the diagnosis of acute cholecystitis with coexistent acute pancreatitis. Eur J Trauma Emerg Surg 43(1):79–83. https://doi.org/10.1007/s00068-015-0619-4

    Article  CAS  PubMed  Google Scholar 

  36. Koo BC, Chinogureyi A, Shaw AS (2010) Imaging acute pancreatitis. Br J Radiol 83(986):104–112. https://doi.org/10.1259/bjr/13359269

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Surlin V, Saftoiu A, Dumitrescu D (2014) Imaging tests for accurate diagnosis of acute biliary pancreatitis. World J Gastroenterol 20(44):16544–16549. https://doi.org/10.3748/wjg.v20.i44.16544

    Article  PubMed  PubMed Central  Google Scholar 

  38. Neoptolemos JP et al (2005) The urgent diagnosis of gallstones in acute pancreatitis: a prospective study of three methods. Br J Surg 71(3):230–233. https://doi.org/10.1002/bjs.1800710324

    Article  Google Scholar 

  39. Shah AP, Mourad MM, Bramhall SR (2018) Acute pancreatitis: current perspectives on diagnosis and management. J Inflamm Res 11:77–85. https://doi.org/10.2147/jir.s135751

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Baron RL et al (1983) Computed tomographic features of biliary obstruction. AJR Am J Roentgenol 140(6):1173–1178

    Article  CAS  Google Scholar 

  41. Vege SS et al (2018) Initial medical treatment of acute pancreatitis: American Gastroenterological Association Institute technical review. Gastroenterology 154(4):1103–1139. https://doi.org/10.1053/j.gastro.2018.01.031

    Article  PubMed  Google Scholar 

  42. O’Connor OJ, McWilliams S, Maher MM (2011) Imaging of acute pancreatitis. AJR Am J Roentgenol 197(2):W221–W225. https://doi.org/10.2214/ajr.10.4338

    Article  PubMed  Google Scholar 

  43. Alexakis N, Neoptolemos JP (2005) Algorithm for the diagnosis and treatment of acute biliary pancreatitis. Scand J Surg 94(2):124–129. https://doi.org/10.1177/145749690509400208

    Article  CAS  PubMed  Google Scholar 

  44. Perera M et al (2013) A case of concomitant perforated acute cholecystitis and pancreatitis. Case Rep Surg 2013:263046. https://doi.org/10.1155/2013/263046

    Article  PubMed  PubMed Central  Google Scholar 

  45. Friedman GD (1993) Natural history of asymptomatic and symptomatic gallstones. Am J Surg 165(4):399–404

    Article  CAS  Google Scholar 

  46. Catalano OA et al (2009) Biliary infections: spectrum of imaging findings and management. Radiographics 29(7):2059–2080. https://doi.org/10.1148/rg.297095051

    Article  PubMed  Google Scholar 

  47. Reynolds BM, Dargan EL (1959) Acute obstructive cholangitis; a distinct clinical syndrome. Ann Surg 150(2):299–303. https://doi.org/10.1097/00000658-195908000-00013

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Bader TR et al (2001) MR imaging findings of infectious cholangitis. Magn Reson Imaging 19(6):781–788. https://doi.org/10.1016/s0730-725x(01)00401-5

    Article  CAS  PubMed  Google Scholar 

  49. Ahmed M (2018) Acute cholangitis - an update. World J Gastrointest Pathophysiol 9(1):1–7. https://doi.org/10.4291/wjgp.v9.i1.1

    Article  PubMed  PubMed Central  Google Scholar 

  50. Lee JG (2009) Diagnosis and management of acute cholangitis. Nat Rev Gastroenterol Hepatol 6(9):533–541. https://doi.org/10.1038/nrgastro.2009.126

    Article  PubMed  Google Scholar 

  51. Lai EC, Lau WY (2006) Mirizzi syndrome: history, present and future development. ANZ J Surg 76(4):251–257. https://doi.org/10.1111/j.1445-2197.2006.03690.x

    Article  PubMed  Google Scholar 

  52. Beltran MA (2012) Mirizzi syndrome: history, current knowledge and proposal of a simplified classification. World J Gastroenterol 18(34):4639–4650. https://doi.org/10.3748/wjg.v18.i34.4639

    Article  PubMed  PubMed Central  Google Scholar 

  53. Beltran MA, Csendes A (2005) Mirizzi syndrome and gallstone ileus: an unusual presentation of gallstone disease. J Gastrointest Surg 9(5):686–689. https://doi.org/10.1016/j.gassur.2004.09.058

    Article  PubMed  Google Scholar 

  54. Beltran MA, Csendes A, Cruces KS (2008) The relationship of Mirizzi syndrome and cholecystoenteric fistula: validation of a modified classification. World J Surg 32(10):2237–2243. https://doi.org/10.1007/s00268-008-9660-3

    Article  PubMed  Google Scholar 

  55. Csendes A et al (1989) Mirizzi syndrome and cholecystobiliary fistula: a unifying classification. Br J Surg 76(11):1139–1143. https://doi.org/10.1002/bjs.1800761110

    Article  CAS  PubMed  Google Scholar 

  56. Abou-Saif A, Al-Kawas FH (2002) Complications of gallstone disease: Mirizzi syndrome, cholecystocholedochal fistula, and gallstone ileus. Am J Gastroenterol 97(2):249–254. https://doi.org/10.1111/j.1572-0241.2002.05451.x

    Article  PubMed  Google Scholar 

  57. Lubbers EJ (1983) Mirizzi syndrome. World J Surg 7(6):780–785. https://doi.org/10.1007/bf01655221

    Article  CAS  PubMed  Google Scholar 

  58. Montefusco P, Spier N, Geiss AC (1983) Another facet of Mirizzi’s syndrome. Arch Surg 118(10):1221–1223. https://doi.org/10.1001/archsurg.1983.01390100083021

    Article  CAS  PubMed  Google Scholar 

  59. Dietrich KF (1963) Stenosis of the hepatic duct in lithiasis of the gallbladder neck and cystic duct (Mirizzi syndrome). Bruns Beitr Klin Chir 206:9–22

    CAS  PubMed  Google Scholar 

  60. Redaelli CA et al (1997) High coincidence of Mirizzi syndrome and gallbladder carcinoma. Surgery 121(1):58–63

    Article  CAS  Google Scholar 

  61. Beltrán MA (2012) Mirizzi syndrome: history, current knowledge and proposal of a simplified classification. World J Gastroenterol 18(34):4639–4650

    Article  Google Scholar 

  62. Solis-Caxaj CA (2009) Mirizzi syndrome: diagnosis, treatment and a plea for a simplified classification. World J Surg 33(8):1783–1784. https://doi.org/10.1007/s00268-009-9929-1

    Article  PubMed  Google Scholar 

  63. Shirah BH, Shirah HA, Albeladi KB (2017) Mirizzi syndrome: necessity for safe approach in dealing with diagnostic and treatment challenges. Ann Hepatobiliary Pancreat Surg 21(3):122–130. https://doi.org/10.14701/ahbps.2017.21.3.122

    Article  PubMed  PubMed Central  Google Scholar 

  64. Tan KY et al (2004) Mirizzi syndrome: noteworthy aspects of a retrospective study in one centre. ANZ J Surg 74(10):833–837. https://doi.org/10.1111/j.1445-1433.2004.03184.x

    Article  PubMed  Google Scholar 

  65. Choi BW et al (2000) Radiologic findings of Mirizzi syndrome with emphasis on MRI. Yonsei Med J 41(1):144–146. https://doi.org/10.3349/ymj.2000.41.1.144

    Article  CAS  PubMed  Google Scholar 

  66. Chen H et al (2018) Current trends in the management of Mirizzi Syndrome: a review of literature. Medicine (Baltimore) 97(4):e9691. https://doi.org/10.1097/md.0000000000009691

    Article  Google Scholar 

  67. Balent E, Plackett TP, Lin-Hurtubise K (2012) Cholecystocolonic fistula. Hawaii J Med Public Health 71(6):155–157

    PubMed  PubMed Central  Google Scholar 

  68. Liang X et al (2015) Comparative analysis of MDCT and MRI in diagnosing chronic gallstone perforation and ileus. Eur J Radiol 84(10):1835–1842. https://doi.org/10.1016/j.ejrad.2015.06.009

    Article  PubMed  Google Scholar 

  69. Oskam J, Heitbrink M, EeftinckSchattenkerk M (1993) Intermittent gallstone ileus following endoscopic biliary sphincterotomy. A case report. Acta Chir Belg 93(2):43–5

    CAS  PubMed  Google Scholar 

  70. Foss H, Summers J (1942) Intestinal obstruction from gallstones. Ann Surg 115:721

    Article  Google Scholar 

  71. Masannat Y, Masannat Y, Shatnawei A (2006) Gallstone ileus: a review. Mt Sinai J Med 73(8):1132–1134

    PubMed  Google Scholar 

  72. Halabi WJ et al (2014) Surgery for gallstone ileus: a nationwide comparison of trends and outcomes. Ann Surg 259(2):329–335. https://doi.org/10.1097/sla.0b013e31827eefed

    Article  PubMed  Google Scholar 

  73. Alemi F, Seiser N, Ayloo S (2019) Gallstone disease: cholecystitis, Mirizzi syndrome, Bouveret syndrome, gallstone ileus. Surg Clin North Am 99(2):231–244. https://doi.org/10.1016/j.suc.2018.12.006

    Article  PubMed  Google Scholar 

  74. Lassandro F et al (2005) Role of helical CT in diagnosis of gallstone ileus and related conditions. AJR Am J Roentgenol 185(5):1159–1165. https://doi.org/10.2214/ajr.04.1371

    Article  PubMed  Google Scholar 

  75. Prasad RM, Weimer KM, Baskara A (2017) Gallstone ileus presenting as intussusception: a case report. Int J Surg Case Rep 30:37–39. https://doi.org/10.1016/j.ijscr.2016.11.036

    Article  PubMed  Google Scholar 

  76. Ayantunde AA, Agrawal A (2007) Gallstone ileus: diagnosis and management. World J Surg 31(6):1292–1297. https://doi.org/10.1007/s00268-007-9011-9

    Article  CAS  PubMed  Google Scholar 

  77. Beuran M, Ivanov I, Venter MD (2010) Gallstone ileus–clinical and therapeutic aspects. J Med Life 3(4):365–371

    CAS  PubMed  PubMed Central  Google Scholar 

  78. Yu CY et al (2005) Value of CT in the diagnosis and management of gallstone ileus. World J Gastroenterol 11(14):2142–2147. https://doi.org/10.3748/wjg.v11.i14.2142

    Article  PubMed  PubMed Central  Google Scholar 

  79. Jakubauskas M, et al. (2019) Gallstone ileus: management and clinical outcomes. Medicina (Kaunas) 55(9). https://doi.org/10.3390/medicina55090598

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Authors and Affiliations

  1. Emory University School of Medicine, Atlanta, GA, USA

    Andrew Tran & Karunesh Polireddy

  2. Div. Emergency and Trauma Imaging, Department of Radiology and Imaging Sciences, Emory University Hospital Midtown, Atlanta, USA

    Carrie Hoff & Kiran Maddu

  3. Department of Radiology, MedStar Health, Washington, DC, USA

    Arie Neymotin

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  1. Andrew Tran
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  2. Carrie Hoff
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  3. Karunesh Polireddy
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  4. Arie Neymotin
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  5. Kiran Maddu
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Contributions

Dr. Kiran Maddu, Dr. Carrie Hoff, and Dr. Arie Neymotin contributed to the study conception. All authors contributed to the design. Material preparation, including images, was performed by Dr. Maddu, Dr. Hoff, and Dr. Neymotin. The first draft of the manuscript was written by Andrew Tran, Karunesh Polireddy, Dr. Kiran Maddu, Dr. Carrie Hoff, and Dr. Arie Neymotin. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Tran, A., Hoff, C., Polireddy, K. et al. Beyond acute cholecystitis—gallstone-related complications and what the emergency radiologist should know. Emerg Radiol 29, 173–186 (2022). https://doi.org/10.1007/s10140-021-01999-y

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