What is cholelithiasis with pericholecystic stranding?

Cholelithiasis with Pericholecystic Stranding: Diagnosis and Clinical Significance

Cholelithiasis with pericholecystic stranding represents gallstones with inflammation extending beyond the gallbladder wall, indicating acute cholecystitis that requires prompt surgical intervention through early laparoscopic cholecystectomy within 7-10 days of symptom onset. 1

Definition and Pathophysiology

Cholelithiasis refers to the presence of gallstones within the gallbladder, affecting approximately 15% of the US population 2. Pericholecystic stranding is an imaging finding that indicates inflammation has spread beyond the gallbladder wall into the surrounding tissues. This appears as:

• Hypo- or anechoic regions seen along the anterior surface of the gallbladder within the hepatic parenchyma on ultrasound 3
• Inflammatory changes in the fat and tissues surrounding the gallbladder on CT imaging 3
• A band of low-level echoes or poorly defined hypoechoic masses surrounding the gallbladder on ultrasound 4

Diagnostic Features

Ultrasound Findings (First-Line Imaging)

• Gallstones: Echogenic structures with posterior acoustic shadowing 3
• Thickened gallbladder wall (>3mm) 3
• Pericholecystic fluid/stranding 3
• Sonographic Murphy's sign: Tenderness when the probe compresses the gallbladder 3
• Distended gallbladder (transverse diameter >5cm) 3

CT Findings

• Gallbladder wall thickening
• Pericholecystic inflammation and stranding
• Adjacent liver parenchymal hyperemia (an early finding in acute cholecystitis) 3
• Gallstones may be visible depending on their composition 3

Clinical Significance

Pericholecystic stranding is a significant finding that indicates:

1. Active inflammation extending beyond the gallbladder wall
2. Acute cholecystitis rather than simple cholelithiasis 3
3. Risk for complications including perforation, abscess formation, or progression to more severe disease 4
4. Need for surgical intervention rather than conservative management 3

Management Algorithm

Step 1: Confirm Diagnosis

• Ultrasound is the first-line imaging modality with sensitivity of 81-88% and specificity of 80-83% for gallstone disease 1
• If ultrasound is equivocal but clinical suspicion remains high, consider:
  • CT with IV contrast to better visualize pericholecystic inflammation 3
  • HIDA scan (sensitivity 86.7-89.3%, specificity 66.8-79%) for functional assessment 1

Step 2: Initial Management

• NPO status
• IV fluid resuscitation
• Electrolyte correction
• Pain control
• Antibiotic therapy 1
  • For non-critically ill patients: Amoxicillin/Clavulanate 2g/0.2g q8h or Eravacycline 1 mg/kg q12h
  • For critically ill patients: Piperacillin/tazobactam or Eravacycline

Step 3: Definitive Treatment

• Early laparoscopic cholecystectomy (within 7-10 days of symptom onset) is the preferred approach 3, 1
• If surgery must be delayed beyond 10 days, consider delaying until after 45 days unless there are signs of worsening peritonitis or sepsis 3
• For high-risk surgical candidates, percutaneous cholecystostomy may be considered as a bridge to intervention 1

Special Considerations

Complications to Monitor

• Pericholecystic abscess formation following gallbladder perforation 4
• Progression to cholangitis if common bile duct is involved 5
• Development of adhesions, which may complicate laparoscopic surgery 6

Surgical Implications

• Pericholecystic stranding may increase the technical difficulty of laparoscopic cholecystectomy
• Higher risk of conversion to open cholecystectomy, particularly with dense adhesions 6
• Early surgical consultation is recommended even with equivocal physical findings 1

Common Pitfalls

1. Misdiagnosis: Not all gallstones cause symptoms or require intervention, but pericholecystic stranding indicates active inflammation requiring treatment 7
2. Delayed treatment: Postponing surgery in acute cholecystitis with pericholecystic stranding increases risk of complications 3
3. Inadequate imaging: Relying solely on ultrasound findings of gallstones without assessing for pericholecystic changes may underestimate disease severity 3
4. Overlooking common bile duct involvement: Always assess for common bile duct dilatation or stones, which may require additional intervention 3

Pericholecystic stranding represents a significant finding that differentiates uncomplicated cholelithiasis from acute cholecystitis requiring prompt surgical intervention to prevent potentially life-threatening complications.