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CT Findings in Acute Gangrenous Cholecystitis

¹ All authors: Department of Abdominal Radiology, New York University Medical Center, Tisch Hospital, Rm. HW202, 560 First Ave., New York, NY 10016.

Received June 12, 2001; accepted after revision August 7, 2001.

 
Address correspondence to G. L. Bennett.

Abstract

Top Abstract Introduction Materials and Methods Results Discussion References

 
OBJECTIVE. The purpose of this study was to determine the CT findings in acute gangrenous cholecystitis.

MATERIALS AND METHODS. Four observers retrospectively reviewed CT scans in 75 patients (23 with acute gangrenous cholecystitis, 25 with acute nongangrenous cholecystitis, and 27 without cholecystitis). The following findings were evaluated: distention, mural thickening, wall enhancement, irregular wall, wall striation, intraluminal membranes, pericholecystic inflammation, gallstones, pericholecystic fluid, enhancement of liver parenchyma, pericholecystic abscess, and gas in the wall or lumen. Sensitivity and specificity of CT for gangrenous cholecystitis and for each finding were calculated. Two reviewers in consensus measured gallbladder dimension and wall thickness. Logistic regression models were used to predict gangrenous versus nongangrenous cholecystitis.

RESULTS. Sensitivity, specificity, and accuracy of CT for acute cholecystitis were 91.7%, 99.1%, and 94.3%, respectively, and for acute gangrenous cholecystitis were 29.3%, 96.0%, and 64.1%, respectively. Findings with the highest specificity for gangrenous cholecystitis were gas in the wall or lumen (100%), intraluminal membranes (99.5%), irregular or absent wall (97.6%), and abscess (96.6%). The difference between the mean gallbladder wall thickness and the short-axis dimension for the two groups with cholecystitis was statistically significant. In three patients with gangrenous cholecystitis, no mural enhancement was seen. Pericholecystic fluid also achieved statistical significance for the diagnosis of gangrene. Multivariate logistic regression analysis showed that the overall accuracy of CT for gangrenous cholecystitis was 86.7%.

CONCLUSION. CT findings most specific for acute gangrenous cholecystitis are gas in the wall or lumen, intraluminal membranes, irregular wall, and pericholecystic abscess. Gangrenous cholecystitis is associated with a lack of mural enhancement, pericholecystic fluid, and a greater degree of gallbladder distention and wall thickening.

Introduction

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Gangrenous or necrotizing cholecystitis is a severe advanced form of acute cholecystitis with a higher morbidity and mortality rate than uncomplicated acute cholecystitis [1]. Clinical and laboratory characteristics are often nonspecific and indistinguishable from those in patients with acute cholecystitis without gangrene, and the diagnosis is often not made preoperatively [2, 3].

Both sonographic and CT findings of acute gangrenous cholecystitis have been previously described [4,5,6,7,8,9,10]. CT findings include intraluminal membranes, hemorrhage into the lumen, and irregular or absent wall, a finding best observed with contrast-enhanced CT [11]. However, the CT findings in large series of patients with gangrenous cholecystitis compared with those of uncomplicated acute cholecystitis and normal patients have not been described, and, to our knowledge, the accuracy of CT for diagnosing this complication is unknown.

The purpose of this study was to describe the CT findings in a large series of patients with acute gangrenous cholecystitis and to compare CT findings in these patients with those of patients with acute nongangrenous cholecystitis. Our goal was to identify those CT findings that would allow for an accurate preoperative diagnosis of gangrenous cholecystitis, so that the surgeon may be informed of this potential complication.

Materials and Methods

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Patients
A search of the pathology database from 1995 to 2000 at two hospitals was performed to identify all patients with a pathologic diagnosis of acute cholecystitis. This yielded a total number of 803 patients. Those patients with a pathologic diagnosis of gangrenous or necrotizing cholecystitis were then identified on the basis of the presence of transmural acute inflammation and necrosis or gangrene of the gallbladder wall. This process yielded 102 patients. The radiology database was searched to identify those patients who underwent CT before surgery. Thirty patients with a pathologic diagnosis of gangrenous cholecystitis underwent preoperative CT, and 23 of these patients underwent CT performed with IV contrast material. These patients constituted the study population. There were 14 men and nine women with ages ranging from 38 to 96 years (mean age, 67 years). The average time between CT and surgery was 2.2 days, with a range of 0-5 days. We also searched for patients with acute cholecystitis without pathologic evidence of necrosis or gangrene and retrieved the CT scans of 25 of these patients, also obtained with IV contrast material. In this group, there were 12 men and 13 women with ages ranging from 33 to 86 years (mean age, 66 years). The average time between CT and surgery was 3.3 days (range, 0-10 days). CT scans of 27 patients with abdominal CT with IV contrast material obtained for reasons other than right upper quadrant pain were also reviewed. These patients constituted the "normal" control population. The 27 patients in the normal control population included 17 women and 10 men with ages ranging from 19 to 72 years (mean age, 42 years).

CT Technique
CT scans were obtained using helical technique with either a HiSpeed or CTI scanner (General Electric Medical Systems, Milwaukee, WI). All patients included in the study received IV contrast material, with injection rates of 2 or 3 mL/sec. Slice thickness varied from 3 to 10 mm. In the gangrenous cholecystitis group, slice thickness in 16 patients was 7 mm, in three patients was 3 mm, and in two patients each was 5 and 10 mm. In the nongangrenous acute cholecystitis group, slice thickness in 11 patients was 3 mm, in seven patients was 7 mm, in four patients was 5 mm, and in three patients was 10 mm. In the group without cholecystitis, slice thickness was 7 mm in 24 patients, 5 mm in two patients, and 3 mm in one patient.

Radiologic Interpretation
The studies were randomized and retrospectively reviewed individually by four experienced abdominal radiologists unaware of the pathologic diagnosis. The reviewers were informed that the cases included a mix of patients with normal gallbladders, acute uncomplicated cholecystitis, and gangrenous cholecystitis. The reviewers were asked to identify the presence of the following 11 findings: gallbladder distention (qualitative assessment), gallbladder wall thickening (>3 mm), gallstones, pericholecystic fluid, pericholecystic fat stranding (increased soft-tissue density in the pericholecystic fat), striated wall (alternating areas of low and high attenuation), focally increased enhancement of adjacent liver parenchyma, pericholecystic abscess (encapsulated fluid collection adjacent to the gallbladder), intraluminal membranes (irregular intraluminal linear and soft-tissue densities), irregular or absent wall (irregular contour or enhancement), and gas in the wall or lumen. Reviewers were also asked to assess for the presence or absence of contrast enhancement of the gallbladder wall, to decide if acute cholecystitis was present, and to rank the likelihood of gangrenous cholecystitis on a 5-point scale as follows: 1, definitely not gangrenous cholecystitis; 2, probably not gangrenous cholecystitis; 3, not sure; 4, probably gangrenous cholecystitis; 5, definitely gangrenous cholecystitis. These rankings were based on assessment of the overall severity of inflammatory changes and pericholecystic abscess or fluid collection. To calculate overall sensitivity and specificity of CT for gangrenous cholecystitis, a score of 4 or 5 was considered positive for gangrenous cholecystitis.

Two additional observers (not included in the previously mentioned four and also unaware of the pathologic diagnosis) reviewed the images in consensus to determine the gallbladder dimensions for all three groups (short axis and long axis) and the gallbladder wall thickness. The long-axis and short-axis dimensions of the gallbladder and wall thickness were measured from outer wall to outer wall using hand held calipers. These two reviewers also performed a consensus evaluation of the presence of each of the CT findings described previously to determine the frequency of each finding in the patients with gangrenous cholecystitis versus those with uncomplicated acute cholecystitis and the normal controls.

Statistical Methods
Data from the four reviewers were used to assess the overall sensitivity, specificity, and accuracy of a CT diagnosis of acute cholecystitis and for acute gangrenous cholecystitis. Values were calculated separately for each reviewer and also using combined observations. Sensitivity and specificity for each of the individual findings described previously were also calculated on the basis of combined reviews. The association between each of the 11 CT findings and the presence of gangrenous cholecystitis was evaluated using chisquare tests. Bonferroni correction was used to compensate for multiple comparisons. The short-axis and long-axis dimensions and the gallbladder wall thickness for the three groups were compared using the t test, with a p value of 0.05 deemed to be significant. Logistic regression models were used to predict acute cholecystitis versus normal gallbladder and gangrenous versus nongangrenous cholecystitis on the basis of data from the consensus observations of two reviewers.

Results

Top Abstract Introduction Materials and Methods Results Discussion References

 
The overall sensitivity, specificity, and accuracy of CT for the detection of acute cholecystitis and for acute gangrenous cholecystitis are indicated in Table 1. On the basis of combined data from four reviewers, CT achieved a high specificity for the diagnosis of acute gangrenous cholecystitis (96%) with a low sensitivity (29.3%). The sensitivity and specificity of individual CT findings of gangrenous cholecystitis and the frequency of each of these findings in the study population are indicated in Table 2. The CT findings with the highest specificity for gangrenous cholecystitis were gas in the wall or lumen (Fig. 1), intraluminal membranes (Fig. 2), irregular or absent wall (Fig. 3A), and pericholecystic abscess (Fig. 3B). Striated wall also achieved a relatively high specificity of 89.9% but was also observed in four patients with nongangrenous cholecystitis (Figs. 4 and 5). The presence of adjacent hepatic enhancement also achieved a relatively high specificity of 89.3% but was observed in six patients with nongangrenous cholecystitis (Figs. 6A,6B and 7). Pericholecystic fluid was observed in eight patients with gangrenous cholecystitis and two patients with nongangrenous cholecystitis (Figs. 8 and 9). The most common CT findings in gangrenous cholecystitis were distention, wall thickening, pericholecystic inflammation, gallstones, irregular or absent wall, and adjacent hepatic enhancement. The p values achieved for irregular or absent wall and pericholecystic fluid were 0.00001 and 0.0001, respectively, for distinction of gangrenous versus nongangrenous cholecystitis. These were the only findings that achieved statistical significance, probably because of the small number of observations.

View larger version (151K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 1. —58-year-old man with acute gangrenous cholecystitis. CT scan with IV contrast material shows air in gallbladder lumen (arrow).

View larger version (140K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 2. —86-year-old man with acute gangrenous cholecystitis. CT scan with IV contrast material shows intraluminal linear densities (black arrows) corresponding to intraluminal membranes. Note lack of contrast enhancement of gallbladder wall (open arrow). Pericholecystic inflammation (white arrow) and adjacent renal cyst (c) are visualized.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3A. —84-year-old woman with acute gangrenous cholecystitis. CT scan with IV contrast material shows irregularity of wall (black arrows) of gallbladder (g) and inflammation in pericholecystic fat (white arrow). s = stomach.

View larger version (127K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 3B. —84-year-old woman with acute gangrenous cholecystitis. CT scan, more superior than A, shows loculated fluid attenuation abnormality adjacent to gallbladder, consistent with abscess (a). Defect in gallbladder wall is shown (black arrow). White arrow shows pericholecystic inflammation. s = stomach.

View larger version (143K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 4. —89-year-old woman with acute gangrenous cholecystitis. CT scan with IV contrast material shows markedly distended gallbladder with irregular wall showing striated appearance with alternating areas of high (black arrows) and low attenuation (small white arrow). Large gallstone (asterisk) is present in gallbladder lumen. Large white arrow shows pericholecystic inflammation.

View larger version (112K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 5. —58-year-old woman with acute nongangrenous cholecystitis. CT scan with IV contrast material shows markedly thickened gallbladder wall with alternating areas of high (black arrows) and low attenuation (short white arrow), giving striated appearance. Gallbladder wall appears regular and intact. Note enhancing vessel in gallbladder wall (long white arrow).

View larger version (137K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6A. —84-year-old woman with acute gangrenous cholecystitis. CT scan with IV contrast material depicts increased contrast enhancement of liver parenchyma adjacent to gallbladder fossa (arrows).

View larger version (141K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 6B. —84-year-old woman with acute gangrenous cholecystitis. CT scan, more inferior than A, shows marked distention of gallbladder (g) with mural thickening (arrow).

View larger version (145K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 7. —77-year-old man with acute nongangrenous cholecystitis. CT scan with IV contrast material shows mildly distended gallbladder with mild wall thickening (white arrow). Note increased enhancement of liver adjacent to gallbladder (black arrows).

View larger version (115K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 8. —38-year-old woman with acute gangrenous cholecystitis. CT scan with IV contrast material shows extensive pericholecystic fluid (white arrows). Intraluminal linear high density corresponds to intraluminal membrane (black arrows).

View larger version (121K): [in this window] [in a new window] [as a PowerPoint slide]   Fig. 9. —50-year-old woman with acute nongangrenous cholecystitis. CT scan shows pericholecystic fluid (arrows).

In three patients with gangrenous cholecystitis, there was no observable IV contrast enhancement of the gallbladder wall (Fig. 2). However, scans of all patients with uncomplicated acute cholecystitis showed mural enhancement. Additionally, in a total of 14 patients (three patients with gangrenous cholecystitis and 11 patients with acute nongangrenous cholecystitis), an enhancing vessel in the wall of the gallbladder was incidentally noted (Fig. 5). These patients were studied during rapid infusion of IV contrast material (3 mL/sec) with 3 mm collimation. This finding was not observed in any of the patients without cholecystitis.

The mean gallbladder size in short-axis and long-axis dimension and the mean gallbladder wall thickness determined from the consensus observation are given in Table 3. A statistically significant difference was seen in the size of the gallbladder in short axis for the gangrenous gallbladders versus the nongangrenous gallbladders (p = 0.01) and between both groups and the normal gallbladders (p < 0.001). No statistical difference was found between the two groups with cholecystitis with respect to long-axis dimension (p = 0.12), although a statistically significant difference was found between the two groups with cholecystitis with respect to wall thickness (p = 0.02).

Excellent prediction of acute cholecystitis is possible using a multivariate logistic regression model involving CT characteristics. The overall accuracy of such a model was 95.8%; sensitivity, 95.6%; and specificity, 96.3%. The forward selection based on conditional parameter removal revealed that virtually identical prediction is possible using the combination of only four key characteristics: wall thickness (p < 0.0001), the short-axis dimension (p < 0.0001), the presence of stones (p = 0.006), and the presence of fluid (p = 0.05). Prediction of gangrenous versus nongangrenous acute cholecystitis using a multivariable logistic regression model was also possible but slightly less accurate. The best model achieved an overall accuracy of 86.7%, sensitivity of 85.7%, and specificity of 87.5%. The key independent variables were the presence of an irregular wall (p = 0.0006), lack of wall enhancement (p = 0.0008), measured wall thickness (p = 0.008), and the short-axis dimension of the gallbladder (p = 0.03). If the measured dimensions were not available, then a model based on remaining characteristics showed a sensitivity decrease to the 72.7% level.

Discussion

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Either sonography or radionuclide imaging usually serves as the first-line imaging modality for the evaluation of patients with clinically suspected acute cholecystitis. However, CT can play an important role in evaluation of these patients if sonography is inconclusive or if radionuclide imaging is not available. Furthermore, CT is often performed if acute cholecystitis is not the primary diagnostic consideration at the time of imaging. The CT features of acute cholecystitis have been described [7, 8, 12,13,14] and include a distended gallbladder with thickened wall, pericholecystic inflammatory change, and fluid. Gallstones may or may not be visualized. Transient hepatic attenuation difference in the adjacent liver may also be noted caused by hyperemia related to adjacent inflammation and increased contrast enhancement [15, 16]. CT also plays an important role in the detection of complications related to cholecystitis, such as gallbladder perforation with pericholecystic abscess or emphysematous cholecystitis [9, 10].

Gangrenous cholecystitis is a severe form of acute cholecystitis, which results from marked distention of the gallbladder with increased tension in the wall. Associated inflammation leads to ischemic necrosis of the gallbladder wall, with or without associated cystic artery thrombosis [17]. The incidence of gangrenous cholecystitis ranges from 2% to 29.6% in various surgical series [1,2,3, 18] and generally occurs in older patients. There is an increased incidence in men and in patients with coexisting cardiovascular disease and leukocytosis greater than 17,000 WBC/mL [18, 19]. Once the disease is suspected, patients with gangrenous cholecystitis generally undergo emergency cholecystectomy or cholecystostomy to avoid life-threatening complications. These patients frequently require an open surgical procedure rather than laparoscopic cholecystectomy, with conversion rates from laparoscopic to open cholecystectomy ranging from 8% to 75% [19,20,21,22].

The hallmark on sonography of gangrenous cholecystitis is the presence of heterogeneous or striated thickening of the gallbladder wall, which is often irregular with projections into the lumen and pericholecystic fluid collections [4,5,6]. The presence of intraluminal membranes representing desquamative gallbladder mucosa is a specific finding but is less common. Sonographic findings typical of uncomplicated acute cholecystitis may be absent in this subset of patients. In a recent surgical series of patients with gangrenous cholecystitis, 28% of patients had a sonogram that was not diagnostic of gallbladder inflammation, mainly because of an absent sonographic Murphy sign and gallbladder wall thickness of less than 3 mm [18]. Another report found the sonographic Murphy sign positive in only 33% of these patients [23]. It is postulated that this finding is related to denervation of the gallbladder wall.

CT findings in gangrenous cholecystitis have also been described, including intraluminal membranes, hemorrhage into the lumen, and irregular or absent wall [7,8,9,10,11]. However, the overall accuracy of CT for the diagnosis of acute gangrenous cholecystitis and the sensitivity and specificity of these findings have not been well evaluated previously.

In our series, CT had high sensitivity and specificity for the diagnosis of acute cholecystitis with an overall accuracy of 94.3%. These findings support the conclusion that CT is a reliable imaging modality to establish a confident diagnosis of acute cholecystitis. CT is also highly specific (96.0%) for identifying patients with acute gangrenous cholecystitis but is insensitive (29.3%). The findings most specific for the diagnosis of gangrenous cholecystitis are gas in the wall or lumen, intraluminal membranes, irregular or absent wall, and pericholecystic abscess. Therefore, when these findings are present, the possibility of gangrenous cholecystitis should be strongly considered, particularly for an irregular gallbladder wall, which achieved high specificity and statistical significance. Pericholecystic fluid also achieved statistical significance for the diagnosis of gangrenous cholecystitis, although the specificity was lower, likely caused by the small number of observations. However, these results indicate that the presence of pericholecystic fluid should also be considered predictive of the severity of acute cholecystitis. Mural striation and adjacent hepatic enhancement also achieved relatively high specificity. Unfortunately, the absence of these findings is not as helpful given the low sensitivities achieved.

Our results also show that the greater the degree of gallbladder distention in the short axis and wall thickening, the greater the likelihood of gangrenous cholecystitis. The average dimension of the long axis of the gangrenous gallbladder was 0.9 cm larger than the nongangrenous one, whereas the short axis was 0.7 cm larger. However, only the short axis proved to be statistically significant in discriminating gangrenous from acute nongangrenous cholecystitis. This finding is due to poorer precision of estimating the long axis, with a standard deviation more than twice as large as that for the short axis, and may be related, in part, to limitations related to variable slice thickness.

Logistic regression models show that CT characteristics provide almost perfect (only three of 75 cases misclassified) prediction of acute cholecystitis. Moreover, 96% accuracy was possible using a reduced model involving the knowledge of wall thickness and the short-axis dimension of the gallbladder, the presence of stones, and fluid. Many other variables correlated strongly with the presence of cholecystitis and could be used to construct other predictive models at 95% accuracy level. Prediction of gangrenous cholecystitis is also possible. Good sensitivity (86%) can be achieved using all CT-derived characteristics. Using this model, we identified the key independent variables: irregular wall, lack of wall enhancement, wall thickness, and short-axis dimension.

Our data support the conclusion that if contrast-enhanced CT shows irregular wall enhancement, this finding is specific for gangrenous cholecystitis, as noted by other authors [11]. In our series, complete lack of gallbladder wall enhancement was observed only in those patients with gangrenous cholecystitis, but the total number of patients was too small for statistical analysis. It is apparent that the ability of CT to discriminate between gangrenous and nongangrenous cholecystitis is improved when patients are studied after IV administration of contrast material. An interesting observation was the presence of an enhancing vessel in the wall of the gallbladder in 14 patients with acute cholecystitis and in no patients without cholecystitis. This difference was observed on studies performed with rapid bolus infusion of IV contrast material with 3-mm slice thickness. This finding may be analogous to observations of the cystic artery made on Doppler sonography in patients with acute cholecystitis [24] and may be an interesting subject for further investigation.

Our study has recognized limitations, largely because of the retrospective nature, including bias of the reviewers to cases with positive findings. However, the reviewers knew that normal patients were also included in the mix of cases they were reviewing. There is also likely selection bias because the patients included in both study groups represented only a small percentage of the total number of patients with cholecystitis treated during the study period. The indications for imaging with CT are not known, and possibly only the most ill patients were imaged. Furthermore, there was a variation in time interval between CT scanning and the time of cholecystectomy. However, no statistically significant difference was found between the two study populations, and the mean time to surgery was shorter for the patients with gangrenous cholecystitis. This finding would impact on overall sensitivity and sensitivity of each finding, but not the specificity. Also, there were variations in the CT techniques used with respect to contrast-injection rates and slice thickness, which likely impact our ability to identify findings such as mural striation, intraluminal membranes, and adjacent hepatic enhancement. Last, the total number of observations for many of the findings evaluated in this study was small, limiting assessment of statistical significance.

In conclusion, air in the gallbladder wall or lumen, irregular or absent gallbladder wall, intraluminal membranes, pericholecystic abscess, and lack of gallbladder wall enhancement are specific CT findings of acute cholecystitis complicated by gangrene. Marked gallbladder wall thickening and distention in the short axis, particularly when combined with the previously mentioned findings, are also highly suggestive of gangrenous cholecystitis. Increased contrast enhancement in the adjacent liver parenchyma, wall striation, and pericholecystic fluid are less specific but also useful findings to predict the severity of cholecystitis. When these findings are observed on CT, the possibility of gallbladder necrosis can be suggested. The surgeon can then be informed that more immediate surgical intervention may be necessary with higher possibility of conversion to open cholecystectomy.

References

Top Abstract Introduction Materials and Methods Results Discussion References

 

1. Morfin E, Ponka J, Brush B. Gangrenous cholecystitis. Arch Surg 1968;96:567 -572[Abstract/Free Full Text]
2. Wilson AK, Kozol RA, Salwen WA, Manov LJ, Tennenberg SD. Gangrenous cholecystitis in an urban VA hospital. J Surg Res 1994;56:402 -404[Medline]
3. Ahmad MM, Macon WL. Gangrene of the gallbladder. Am Surg 1983;49:155 -158[Medline]
4. Teefey SA, Baron RL, Radke HM, Bigler SA. Gangrenous cholecystitis: new observations on sonography. J Ultrasound Med 1991;10:603 -606[Abstract]
5. Kane RA. Ultrasonographic diagnosis of gangrenous cholecystitis and empyema of the gallbladder. Radiology 1980;134:191 -194[Abstract/Free Full Text]
6. Jeffrey RB, Laing FC, Wong W, Callen PW. Gangrenous cholecystitis: diagnosis by ultrasound. Radiology 1983;148:219 -221[Abstract/Free Full Text]
7. Paulson EK. Acute cholecystitis: CT findings Semin Ultrasound CT MR 2000;21:56 -63[Medline]
8. Fidler J, Paulson EK, Layfield L. CT evaluation of acute cholecystitis: findings and usefulness in diagnosis. AJR 1996;166:1085 -1088[Abstract/Free Full Text]
9. Lamki N, Raval B, St. Ville E. Computed tomography of complicated cholecystitis. J Comput Assist Tomogr 1986;10:319 -324
10. Varma DGK, Faust JM. Computed tomography of gangrenous acute postoperative acalculous cholecystitis. J Comput Assist Tomogr 1988;12:29 -31
11. Bridges MD, Jones BC, Morgan DE, Fell SC. Acute cholecystitis and gallbladder necrosis: value of contrast enhanced helical CT. (abstr) AJR 1999:172 [American Roentgen Ray Society 99th Annual Meeting Abstract Book suppl]:34 -35
12. Kane RA, Costello P, Duszlak E. Computed tomography in acute cholecystitis: new observations. AJR 1983;141:697 -701[Abstract/Free Full Text]
13. Alterman DD, Hochsztein JG. Computed tomography in acute cholecystitis. Emer Radiol 1996;3:25 -29
14. Mirvis SE, Vainright JR, Nelson AW, et al. The diagnosis of acute acalculous cholecystitis: a comparison of sonography, scintigraphy, and CT. AJR 1986;147:1171 -1175[Abstract/Free Full Text]
15. Yamashita K, Jin MJ, Hirose Y, et al. CT finding of transient focal increased attenuation of the liver adjacent to the gallbladder in acute cholecystitis. AJR 1995;164:343 -346[Abstract/Free Full Text]
16. Ito K, Awaya H, Mitchell DG, et al. Gallbladder disease: appearance of associated transient increased attenuation in the liver at biphasic, contrast-enhanced dynamic CT. Radiology 1997;204:723 -728[Abstract/Free Full Text]
17. Cotran RS, Kumar V, Robbins SL. Pathologic basis of disease, 4th ed. Philadelphia: Saunders, 1989: 971
18. Hunt DRH, Chu FCK. Gangrenous cholecystitis in the laparoscopic era. Aust N Z J Surg 2000;70:428 -430[Medline]
19. Merriam LT, Kanaan SA, Dawes LG, et al. Gangrenous cholecystitis: analysis of risk factors and experience with laparoscopic cholecystectomy. Surgery 1999;126:680 -686[Medline]
20. Jacobs M, Verdeja J, Goldstein HS. Laparoscopic cholecystectomy in acute cholecystitis. J Laparoendosc Surg 1991;1:175 -177[Medline]
21. Singer JA, Mckeen RV. Laparoscopic cholecystectomy for acute or gangrenous cholecystitis. Am Surg 1994;60:326 -328[Medline]
22. Cox M, Wilson T, Luck A, et al. Laparoscopic cholecystectomy for acute inflammation of the gallbladder. Ann Surg 1993;218:630 -634[Medline]
23. Simeone J, Brink J, Mueller P, et al. The sonographic diagnosis of acute gangrenous cholecystitis: importance of the Murphy sign. AJR 1989;152:289 -290[Abstract/Free Full Text]
24. Jeffrey RB, Nino-Marcia M, Ralls PW, et al. Color Doppler sonography of the cystic artery: comparison of normal controls and patients with acute cholecystitis. J Ultrasound Med 1995;14:1 -33[Abstract]

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