Emphysematous cholecystitis: Don’t miss the diagnosis

Jerraya Hichem |

La tunisie chirurgicale - 2019 ; Vol 2019

Resumé

Emphysematous cholecystitis (EC) is a life-threatening surgical emergency. In order to ensure early diagnosis, it is mandatory to recognize the special features of this pathologic entity. We report a case of EC which was strongly evoked preoperatively by plain-film radiography of the abdomen and computed tomography.

Mots Clés

Emphysematous cholecystitis: Don’t miss the diagnosis

Introduction :

Emphysematous cholecystitis (EC) is a life-threatening surgical emergency. In order to ensure early diagnosis, it is mandatory to recognize the special features of this pathologic entity. We report a case of EC which was strongly evoked preoperatively by plain-film radiography of the abdomen and computed tomography.

Article

Case presentation:

A 70-year-old man with a past medical history of coronary bypass surgery and a previous groin hernia repair, complained of right-sided abdominal pain with fever and vomiting for ten days. He denied any similar episodes in the past.Since the onset of symptoms he consulted twice another hospital where an abdominal ultrasonography (US) had been performed without retaining a final diagnosis.At admission in our department, physical examination foundatemperature at 38.5°C, a guarding in the right upper quadrant, a blood pressure of 150/80 mmHg, a pulse rate of 122 beats/min and a breathing rate of 26/min. Laboratory tests showed white blood cell count of 24,220/mm3 and C-reactive protein of 436 mg/l. Liver biochemical tests were normal and renal function tests were in the high normal range. Plain-film radiography of the abdomen showed two superimposed and well-delineated pockets of intra-abdominal gas with an internal air–fluid level in the right upper quadrant of the abdomen (Figure 1). At this stage three diagnoses were evoked, namely subphrenic abscess,complicated duodenal diverticula and emphysematous cholecystitis.Computed tomographyshowed an air–fluid level in the lumen of the gallbladder as well as intramural locules ofgas within the gallbladderwall (Figure 2). These findings were highly suggestive of EC. The double superimposedpockets of gas seen on the plain-film radiography of the abdomen corresponded to the body of gallbladder and its fundus (Figure 3).Thepatient underwent urgent open cholecystectomy. The gallbladder was gangrenous and distended by air (Figure 4). The postoperative course was uneventfuland the patient was discharged home on hospital day 5.

Discussion:

EC is a serious surgical emergency which should be differentiated from common forms of acute cholecystitiswith regard to a poorer prognosis and the need for a more urgent surgery. Indeed the mortality rate associated with EC is about 15% as compared with 4% for common acute cholecystitis [1].To make an early diagnosis of EC, it is imperative to know some key features of this entity.Firstly, about 30% of EC are acalculous[1],suggesting that pathogenesis would be in relation to localischemia secondary to vascular occlusion [2]. This may explainits greater incidence in elderly males with diabetes or atherosclerosis [2,3]. Secondly, as in our case, false negative results on US may occur since small amount of gas in the gallbladder wall may go undetected [4].The same applies for cases where there is an amount of pericholecysticgas which can obscure visualization of the gallbladder[2,5].It is therefore imperative, in the presence of suggestive clinical manifestations of acute cholecystitis, tocheck for abnormal gas in the right upper quadrant of the abdomen on plain-film radiography. To confirm the diagnosis, CT remains the most sensitive and specific imaging modality for identifying gas within the gallbladder lumen or wall[6]. EC require emergent cholecystectomy which could be achieved by laparoscopic approach. However in severely ill patients percutaneous cholecystostomy may be used as an initial temporizing treatment [7]. 

 

 

Références

  1. Mentzer RM Jr, Golden GT, Chandler JG, Horsley JS 3rd.A comparative appraisal of emphysematous cholecystitis.Am J Surg. 1975;129(1):10-5.
  2. Jolly BT, Love JN.Emphysematous cholecystitis in an elderly woman: case report and review of the literature.J Emerg Med. 1993;11(5):593-7.
  3. Chiu HH, Chen CM, Mo LR.Emphysematous cholecystitis.Am J Surg. 2004;188(3):325-6.
  4. Hawass ND.False negative sonographic finding in emphysematous cholecystitis.ActaRadiol. 1988;29(1):137-8.
  5. Zippel D, Shapiro R, Goitein O, Halshtok O, Papa M.Emphysematous cholecystitis: don't be lulled into complacency.J Emerg Med. 2011;41(4):400-1.
  6. Grayson DE, Abbott RM, Levy AD, Sherman PM.Emphysematous infections of the abdomen and pelvis: a pictorial review.Radiographics. 2002;22(3):543-61.
  7. Vingan HL, Wohlgemuth SD, Bell JS 3rd.Percutaneous cholecystostomy drainage for the treatment of acute emphysematous cholecystitis.AJR Am J Roentgenol. 1990;155(5):1013-4.

 

Author Disclosures:

Authors have no conflicts of interest or financial ties to disclose.

 

 

 

Figure 1.tif

Figure 1:         Plain-film radiography of the abdomen showed two gas bubbles in the right upper quadrant (white arrows) with air/fluid level.

Figure 2.tif

Figure 2:         Abdominal CT showed on axial viewsair–fluid level in the lumen of the gallbladder (large arrow) and gas within the gallbladderwall (thin arrows).

 

Figure 3.tif

Figure 3:         On coronal views, CT demonstrated better the bilobed shape of the emphysematous gallbladder (asterisk).

Figure 4.tif

Figure4:          Intraoperative image showing the gangrenous gallbladder (arrow).