Iatrogenic intramural dissection of the gallbladder wall can mimic post-ERCP cholecystitis.

gical management of acute cholecystitis 1 day after endoscopic retrograde cholan− giopancreatography (ERCP) and biliary sphincterotomy, because of the finding of a 15−mm−thick gallbladder wall on right upper quadrant ultrasonography (l" Figure 1). Pre−ERCP ultrasonography (l" Figure 2) and magnetic resonance cholangiopancreatography (l" Figure 3) demonstrated a 2.8−mm gallbladder wall and a patent cystic duct. The fluoroscopic images of the ERCP were reexamined and it was apparent that introduction of the guide wire had caused a dissection of the gallbladder wall which was visualized only after the injury had been exacerbat− ed by injection of contrast intramurally (l" Figure 4). In the absence of fever, leu− kocytosis, a positive Murphy’s sign, or pericholecystic fluid on ultrasound imag− es, the gallbladder wall thickening was concluded to represent an iatrogenic in− jury. We monitored the patient with seri− al abdominal exams to rule out a perfora− tion and were able to discharge her with conservative management alone. Two months later she underwent an elective laparoscopic cholecystectomy for symp− toms attributed to cholecystitis. A mural hematoma was seen upon initial visuali− zation of the gallbladder (l" Figure 5) and confirmed by histopathology. The incidence of post−ERCP acute chole− cystitis is less than 1 % [1,2]. The etiology has been postulated to be the presence of nonsterile contrast medium exacerbated by cystic duct obstruction and mechani− cal irritation [3± 5]. This case represents the first reported occurrence of an intra− mural dissection of the gallbladder wall during ERCP. The subsequent intramural hematoma caused gallbladder wall thick− ening that mimicked post−ERCP cholecys− titis on ultrasonography. While concur− rent development of localized tender− ness, fever, leukocytosis, and perichole− cystic fluid on ultrasonography would strongly suggest post−ERCP cholecystitis, an isolated and sudden increase in gall− bladder wall thickness after ERCP must be evaluated carefully for the possibility Iatrogenic intramural dissection of the gallbladder wall can mimic post−ERCP cholecystitis