COTW 9/22/22: 70M hx of prior etoh dependence, afib presents with palpitations, fatigue
70M hx of alcohol dependence in remission presents with recurrent episodes of Afib with RVR, worsening fatigue, weight loss. He has been seen multiple times in the ED over the last several weeks for palpitations and weakness despite starting rate control with diltiazam which was later switched to metoprolol.
Vitals: HR 130s, BP 118/77, SpO2 98% RA, afebrile
Exam shows a chronically ill appearing man in no acute distress. Like all good providers you do a bedside echo which shows small pericardial effusion without tamponade and no significant right heart strain. He states he’s adherent with his Pradaxa but given this is his 3rd visit for the same symptoms, you send him for CTPE…
…which comes back negative for PE, but does show masses in his liver. In the mean time his LFTs come back elevated (ALT 151, AST 140, T bili 4.5).
SO you bring the ultrasound back to his room for round 2:
RUQ ultrasound showing multiple, hypervascular nodular infiltrates in the liver
Gallbladder lumen filled with heterogenous, mostly low echogenic material
Second long axis view of the gallbladder again showing large, irregularly defined heterogeneous mass within the lumen
Still image above is from the end of the first gallbladder video above, showing dilated CBD filled with hypoechoic material.
The above ultrasound findings in conjunction with the patient’s presentation are concerning for GB malignancy with metastases to the liver, as well as common bile duct obstruction.
In general, 90% of gallbladder cancers are adenocarcinomas, gallstones are present 70-90% of the time, patients are generally elderly and don’t often develop significant symptoms until advanced stages.
Ultrasound findings suggestive of Gallbladder Cancer:
Intraluminal mass
Diffuse mural wall thickening
Mass replacing the gallbladder (most common presentation)
Tumors are often irregularly shaped with ill defined margins and heterogenous echogenicity (generally low echogenicity).
Porcelain gallbladder
Term refers to the blue discoloration of a gallbladder with extensive wall calcifications. These are seen on ultrasound as a poorly defined gallbladder with dense posterior shadowing. This finding is associated with malignancy in ~20-30% of cases. Note in the photo the gallbladder wall is difficult to make out, however the gallbladder is identified by the large area of shadowing
Image courtesy of The Radswiki, Radiopaedia.org, rID: 11806
Case Resolution:
CTAP w/ contrast showed probably primary gallbladder neoplasm with multiple liver metastasis, as well as dense material in gallbladder lumen and distal CBD thought to represent hemorrhage and thrombus.
Patient was admitted for further management, GI was consulted for possible MRCP vs ERCP given CBD obstruction. A biopsy was scheduled for the following week.