Imaging of Acute Cholecystitis: Modality Selection from a Surgeon’s Perspective

on
Acute Cholecystitis: The Surgeon's Eye
Created by Dr. Sharad Maheshwari, imagingsimplified@gmail.com

Radiologists Diagnose.
Surgeons Decide.

If your report doesn't help a surgeon determine safety, it is incomplete. We don't just need to know "Is it cholecystitis?" We need to know "Am I walking into a disaster?"

The Core Mistake

Radiologist asks:

"Is this acute cholecystitis?"

Surgeon asks:

"Is it safe to operate now, or is there perforation, leak, or duct injury?"

Non-Calcified Stones CT vs US
Ultrasound Sensitivity ~95%
CT Sensitivity 60%

CT misses 30-40% of stones.

Perforation Detection CT vs US
Ultrasound Low
CT Sensitivity High

CT is the "Complication Map".

Biliary Anatomy MRCP
Ductal Visualization 99%

Use MRCP for Mirizzi, CBD stones, and surgical planning. Not screening.

Modality Selection

Ultrasound

The First Line

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Why Surgeons Trust It

  • Sonographic Murphy: Dynamic pain correlation.
  • Wall Hyperemia: Sees inflammation before fat stranding.
  • Stone Finder: Sees non-calcified stones & sludge.
"If US is classic + stable patient = Operation. No CT needed."

CT Scan

The Complication Map

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The Reality Check

  • Not a stone finder. Don't rule out Chole just because no stone is seen.
  • Perforation Hunter: Detects gangrene, air, and abscess.
  • Fat stranding is LATE. Early Chole can look "normal".
"Use for toxic patients or suspected perforation."

MRI / MRCP

The Precision Tool

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Strategic Value

  • Map the ducts. Essential for Choledocholithiasis.
  • Mirizzi Syndrome: Avoids bile duct injury.
  • Ductal anatomical variations: Critical surgical roadmap.
  • Not for screening. Don't use to "confirm" cholecystitis.
"Changes the surgical approach, consent, and timing."

The "Sealed Perforation" Trap

This is where radiologists and residents get burned. The omentum seals the hole, the gallbladder remains distended, but bile leaks downward.

KEY POINT: Gallbladder distension does NOT exclude perforation.

Anatomy of a Miss

Distended GB
Omentum Seal
Fluid Tracking Down

The Surgeon's Fear Checklist

If you see these, pick up the phone.

  • Fluid > Inflammation

    If the wall looks okay but there's a ton of fluid, it's a leak.

  • Tracking Fluid

    Subhepatic, paracolic, or pelvic bile. It flows down.

  • Gas (Emphysematous)

    Surgical emergency. High mortality.

Table 1: Surgeon's Perspective Modality Selection

Parameter Ultrasound (US) CT Scan MRI / MRCP
Primary Role First-line diagnosis Problem-solving / Complications Ductal Anatomy
Gallstones Excellent (inc. non-calcified) Limited (Misses 30-40%) Ductal stones, not cystic
Murphy Sign Yes (Key Diagnostic) No No
Sealed Perforation Frequently Missed Reliably Detected Rarely Used
Gangrenous Chole Limited Best Modality Limited
Surgical Question "Is this acute cholecystitis?" "How bad is it and has it broken?" "Where is the bile duct?"

Resident Checklist

Status: PENDING

Case Scenario Quiz

Based on "Acute Cholecystitis Imaging: What Radiologists Must See Through a Surgeon’s Eyes"

Built for Educational Use

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