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

Non-contrast enhanced CT - Emergency room

A non-contrast CT was performed before intravenous contrast injection.

Red arrow: Note the presence of an hypodense gallbladder with some cholelythiasis within.

Blue arrows: Active bleeding secondary to multiple pelvic fractures. An embolization was required.

CT

Non-contrast enhanced CT - 5h

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.

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 enhanced CT - 24 hours

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

Note the presence of a hyperdense gallbladder with multiple cholelithiasis 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 a 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, a contrast-induced nephropathy with increasing values of creatinine was confirmed. 

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Case information

rID: 45792
Published: 8th Jun 2016
Last edited: 14th Aug 2019
Inclusion in quiz mode: Excluded

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