Gallbladder Hydrops with Cholelithiasis in Young Female Patient

Case at a Glance

A 26-year-old female presented with elevated liver function tests and a history of alcohol use disorder. Abdominal ultrasound revealed cholelithiases within a hydropic gallbladder, suggestive of cholecystitis, while liver parenchyma appeared normal.

Patient's Story

The patient sought medical attention due to concerns about her liver health following a period of alcohol abuse. She had recently undergone laboratory testing which revealed elevated liver function tests, prompting her primary care physician to order hepatic imaging to evaluate for potential fatty liver disease or other hepatic pathology.

Initial Assessment

Laboratory findings demonstrated elevated liver function tests in the context of a significant alcohol use history. The patient was initially concerned about potential liver damage, specifically fatty liver disease. Physical examination findings and additional clinical details were pending at the time of imaging.

The Diagnostic Journey

Abdominal ultrasound was performed to evaluate hepatic parenchyma and assess for fatty infiltration or other liver abnormalities. Surprisingly, the liver appeared normal in size and echogenicity with no evidence of steatosis. However, the gallbladder showed evidence of hydrops (distension) with the presence of cholelithiases (gallstones), findings consistent with cholecystitis.

Final Diagnosis

Cholelithiasis with gallbladder hydrops in the setting of cholecystitis. The liver function test abnormalities were likely secondary to gallbladder inflammation rather than primary hepatic pathology.

Treatment Plan

The patient awaited contact from her primary care physician to discuss the imaging findings and determine the appropriate management approach. The treatment plan would depend on the severity of symptoms, clinical presentation, and the complete ultrasound report details.

Outcome and Follow-up

Further clinical correlation was needed to determine the urgency of intervention and whether immediate cholecystectomy would be required. The patient expressed concerns about the need for emergency gallbladder removal and sought reassurance about the immediate risk level.