Peritoneal Pearls in Imaging: Case Study Analysis
PERITONEAL PEARLS
DEEPAK M PAI
Y ELTINAY
SCUNTHORPE GENERAL HOSPITAL
HISTORY
•
45 years old male had CT KUB with h/o
haematuria
•
No renal stones but incidental lesions were
identified with-in the anterior peritoneal
cavity
•
There were about seven of them and
measured between 9 mm and 22 mm.
•
They were round to oval in shape and no
calcification identified
NON-CONTRAST CT KUB
FURTHER SIMILAR FINDINGS
History contd…
•
Nature and significance of these were
uncertain at the time of reporting CT and
hence MRI with liver protocol was
recommended
FAT SUPPRESSED T2W AXIAL IMAGES
FAT SUPPRESSED T2W AXIAL IMAGES
T1W AXIAL IMAGES
POST-GADOLINIUM IMAGES
INTERPRETATION
•
It was not clear as these were not enhancing
and had no consistent signal characters from
all of them.
•
Any idea?
BASIC PRINCIPLES
•
As basic principle in image interpretation, we
started digging into the previous imaging
studies.
•
Patient had CT abdomen and MRCP five years
earlier
CT 5 YEARS EARLIER SHOWING NO SUCH FINDINGS
MRCP 5 YEARS EARLIER
•
Patient had gall stones before and we could
not find gall bladder on the current CT and MR
and hence presumed cholecystectomy in
between.
•
We thought we should check the histology of
cholecystectomy specimen
HISTOLOGY REPORT
•
Gall bladder measuring 115 mm received and
was opened at the fundus.
•
No calculi. Features of chronic cholecystitis.
DIAGNOSIS
•
Spilled calculi in the peritoneal cavity during
lap cholecystectomy
•
Surgical notes confirmed the same
SPILLED GALLSTONES
•
Laparoscopic cholecystectomy is a common
surgical procedure
•
Accidental opening of gall bladder is a relatively
frequent incident(15-40%)
•
Spillage of gall stones into the peritoneal cavity
can occur in 16-66% of perforated GB
•
Complications caused by intraperitoneal gall
stones are infrequent but can be serious
•
Frequent sites of spillage are right
hypochondrium(41%) and pelvis(33%)
•
Risk factors for complications are infected bile,
pigment stones, male, perihepatic location,
>15 stones, size >1.5 cm
•
Time period from spillage to complications
varies but average is 5.5 months but can take
up to 20 years
•
Abscess is the most common complication
•
Anterior abdominal wall and sub hepatic
space are the commonest sites for abscess
•
Other rare complications are
•
Fistulas
•
Adhesions
•
Intestinal perforations
•
Intestinal obstruction
•
Intrahepatic abscess
•
Spontaneous liver bleed
•
Obstructive jaundice
•
Non-infectious collections
BEWARE
•
They can mimic peritoneal metastases in
asymptomatic patients and in staging CTs if
they are not calcified(as in this case)
•
If there is h/o cholecystectomy then the
possibility of spilled calculi has to be
considered
LEARNING POINTS
•
Any nonspecific findings around the liver and
upper abdomen with h/o cholecystectomy
should make you think of spilled gall stones
•
Complications related to spilled gallstones are
varied and can be seen up to 20 years after
surgery
•
Reporting Radiologist has a major role in
diagnosing them and bring it to the attention
of clinicians
THANK YOU FOR YOUR KIND
ATTENTION
A 45-year-old male presented with incidental lesions in the anterior peritoneal cavity during a CT scan for haematuria. These lesions, measuring between 9 mm and 22 mm, were non-enhancing and lacked consistent signal characteristics. Further imaging with MRI was recommended for better evaluation. By comparing with previous imaging studies, including CT and MRCP from five years earlier, the nature and significance of these findings were to be elucidated.
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Presentation Transcript
PERITONEAL PEARLS DEEPAK M PAI Y ELTINAY SCUNTHORPE GENERAL HOSPITAL
HISTORY 45 years old male had CT KUB with h/o haematuria No renal stones but incidental lesions were identified with-in the anterior peritoneal cavity There were about seven of them and measured between 9 mm and 22 mm. They were round to oval in shape and no calcification identified
History contd Nature and significance of these were uncertain at the time of reporting CT and hence MRI with liver protocol was recommended
INTERPRETATION It was not clear as these were not enhancing and had no consistent signal characters from all of them. Any idea?
BASIC PRINCIPLES As basic principle in image interpretation, we started digging into the previous imaging studies. Patient had CT abdomen and MRCP five years earlier
Patient had gall stones before and we could not find gall bladder on the current CT and MR and hence presumed cholecystectomy in between. We thought we should check the histology of cholecystectomy specimen
HISTOLOGY REPORT Gall bladder measuring 115 mm received and was opened at the fundus. No calculi. Features of chronic cholecystitis.
DIAGNOSIS Spilled calculi in the peritoneal cavity during lap cholecystectomy Surgical notes confirmed the same
SPILLED GALLSTONES Laparoscopic cholecystectomy is a common surgical procedure Accidental opening of gall bladder is a relatively frequent incident(15-40%) Spillage of gall stones into the peritoneal cavity can occur in 16-66% of perforated GB Complications caused by intraperitoneal gall stones are infrequent but can be serious Frequent sites of spillage are right hypochondrium(41%) and pelvis(33%)
Risk factors for complications are infected bile, pigment stones, male, perihepatic location, >15 stones, size >1.5 cm Time period from spillage to complications varies but average is 5.5 months but can take up to 20 years Abscess is the most common complication Anterior abdominal wall and sub hepatic space are the commonest sites for abscess
Other rare complications are Fistulas Adhesions Intestinal perforations Intestinal obstruction Intrahepatic abscess Spontaneous liver bleed Obstructive jaundice Non-infectious collections
BEWARE They can mimic peritoneal metastases in asymptomatic patients and in staging CTs if they are not calcified(as in this case) If there is h/o cholecystectomy then the possibility of spilled calculi has to be considered
LEARNING POINTS Any nonspecific findings around the liver and upper abdomen with h/o cholecystectomy should make you think of spilled gall stones Complications related to spilled gallstones are varied and can be seen up to 20 years after surgery Reporting Radiologist has a major role in diagnosing them and bring it to the attention of clinicians
THANK YOU FOR YOUR KIND ATTENTION
