Imaging and Multidisciplinary Management of Acute Cholecystitis With Choledocholithiasis in a Phrygian Cap...

Anatomical variations in the gallbladder, such as a Phrygian cap, can complicate the diagnosis of acute cholecystitis, particularly when associated with choledocholithiasis. We report the case of a 43-year-old female who presented with complaints of right upper quadrant (RUQ) pain, which began one week prior and worsened over two days. The pain was associated with fever, nausea, and two episodes of vomiting the previous night. On admission, blood pressure was 104/66 mmHg, heart rate 61 bpm, respirations 18 bpm, saturating at 96%, pain 6, afebrile. The physical exam showed remarkable RUQ tenderness. Labs on admission were unremarkable apart from abnormal liver function testing (mild elevation of alkaline phosphatase (ALKP) 171 IU/L, alanine aminotransferase (ALT) 72 IU/L, and aspartate aminotransferase (AST) 48 IU/L. Ultrasound showed common bile duct dilation of approximately 11 mm without evidence of radiopaque choledocholithiasis. Sagittal computed tomography (CT) showed a distended and folded gallbladder, illustrating the anatomical variation of the Phrygian cap. Magnetic resonance cholangiopancreatography (MRCP) showed features suggestive of acute calculous cholecystitis and common bile duct filling defect consistent with choledocholithiasis. Hepatobiliary iminodiacetic acid (HIDA) scintigraphy provided evidence of acute cholecystitis and cystic duct obstruction. The patient was successfully treated with endoscopic retrograde cholangiopancreatography (ERCP), followed by a same-day laparoscopic cholecystectomy. Following three days of observation, the patient showed normal vital signs with decreasing epigastric pain. Additionally, lipase and amylase levels decreased from 366 and 1,440 U/L, respectively, to 176 and 100 U/L following ERCP. The patient was discharged home on Day 7 with acetaminophen, omeprazole, and instructions to follow up as an outpatient with both her primary and general surgery within 14 days. This case underscores the critical importance of a stepwise and multidisciplinary approach in the management of a complex case of acute cholecystitis.