Vicarious contrast excretion

Case contributed by Dr Prat-Matifoll

Presentation

Run over by a car with severe abdominal trauma.

Patient Data

Age: 75 years
Gender: Male
CT

Emergency CT study

Red arrow: note the presence of a hypodense gallbladder with some cholelithiasis within.

Blue arrows: active contrast extravasation consistent with active bleeding secondary to multiple pelvic fractures. An embolization was required.

CT

Non-contrast CT - 5 hours

After five hours, the patient presented hemodynamic instability and another CT was performed to rule out active bleeding.

Note the presence of hyperdense content within the gallbladder (red arrow) and how it causes a loss of differentiation between liver parenchyma and gallbladder (yellow arrow). 

A persistent nephrogram can also be seen.

The extravasated intravenous contrast (red arrows) probably related to a bladder rupture (yellow arrows) causing urine to leak into the abdomen.

Blue arrow: Chance fracture (high association with intra-abdominal injuries)

CT

Non-contrast CT - 24 hours

Excretion of intravenous contrast through the hepatobiliary system (vicarious excretion of contrast).

Note the presence of a hyperdense gallbladder with multiple cholelithiases within, some of them not previously visualized due to a lack of calcification in the stone.

Persistent nephrogram and left urethrogram after 24 hours. This finding could help to identify subclinical renal impairment and a higher risk of nephropathy on subsequent exposure to contrast agents. Our patient presented with contrast-induced nephropathy few days later. 

Case Discussion

Gallbladder opacification from vicarious excretion may indicate decreased renal function (remember the suspicion of a bladder rupture in our patient) although it could be seen after injecting a high dose of contrast (a triphasic CT and angiography were performed) without an underlying renal impairment. In our patient, contrast-induced nephropathy with increasing values of creatinine was confirmed. 

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Case information

rID: 45792
Published: 8th Jun 2016
Last edited: 15th Sep 2019
Inclusion in quiz mode: Excluded

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