CASE 10390 Published on 09.10.2012

Emphysematous cholecystitis with focal perforation

Section

Abdominal imaging

Case Type

Clinical Cases

Authors

Yuranga Weerakkody1, Aparna Baruah2, Dieter Weber3

Departments of Radiology and general
SCGH, NMAHS,
Hospital avenue,
6009 Perth, Western Australia
1FRANZCR
2FRCR
3FRACS
Patient

75 years, male

Categories
Area of Interest Biliary Tract / Gallbladder ; Imaging Technique CT
Clinical History
A 76-year-old man presented with a history of feeling generally unwell for 2-3 days, followed by right upper quadrant pain, focal guarding. His liver function tests were deranged on admission. Ultrasound imaging was inconclusive and therefore further evaluation with CT was performed.
Imaging Findings
Contrast enhanced CT examination showed an inflamed gallbladder with an enhancing wall, pericholecystic fluid as well as intramural air along its anterior and inferomedial margins. This was seen on all three planes (Fig. 1a, 2a and 3a). There was also mildly hyper-attenuating dependent sludge within the gallbladder as well as a possible 2 cm radiolucent stone at the gallbladder neck (Fig. 2b and 3b). There was no associated gallbladder mass lesion. Satisfactory fat planes preservation was maintained with the neighbouring duodenum as well as the adjacent colon with no suggestion of any cholecysto-duodenal or cholecysto-colic fistulation. Imaging features are therefore in keeping with emphysematous cholecystitis. In addition, there were also at least two small separate extra-luminal air locules noted anterior to the gallbladder (arrowed on Fig. 1b) which is in keeping with a complicating focal perforation.
Discussion
Emphysematous cholecystitis refers to a specific subtype of acute cholecystitis. Unlike its much more common non-emphysematous form, there is a recognised male predilection with a M:F ratio of around 2:1 [1]. Its incidence peaks at around 50 to 70 years of age. Patients often have a history of underlying diabetes mellitus as well as peripheral atherosclerotic disease. Vascular compromise to the cystic artery is postulated as playing a key role in the evolution of emphysematous cholecystitis and this is thought to partly explain its increased male predilection [1]. Emphysematous cholecystitis is also associated with an increased prevalence of acalculous cholethiasis where gallstones can be absent in as much of half of cases [7]. It also carries an increased risk of associated complications such as gangrenous change and gallbladder perforation (present in this case).
Clinical presentation can often be insidious where up to a third of patients may be afebrile at presentation. Localised tenderness over the gallbladder also tends not to be a dominant clinical feature [5]. Commonly isolated organisms include Clostridium welchii and Escherichia coli.
The radiographic appearance of emphysematous cholecystitis was first published in 1931 by C F Hegner [6]. On imaging, emphysematous cholecystitis is principally diagnosed when there are features of gallbladder inflammation with the additional presence of air which is often in the gallbladder wall but can also be within the lumen of the gallbladder, in tissues adjacent to the gallbladder, or in the biliary ducts. For this diagnosis, there should also be an absence of any abnormal communication with the gastrointestinal tract [2, 4]. At the time of writing, CT is considered the most specific and sensitive modality in assessment of emphysematous cholecystitis [3, 9].
The condition can progress rapidly and requires emergency surgical intervention. It can carry a three to fourteen fold higher mortality rate than that of uncomplicated acute cholecystitis [1-2] and the overall mortality rate can approach 25% [10]. The first choice of treatment in cases presenting with a complicating pneumoperitoneum is an emergency laparotomy [8] while percutaneous cholecystostomy may be an option in those who have contraindications for surgery [11]. This case illustrates the classical imaging features of emphysematous cholecystitis on CT as well as that of an associated perforation (which is a well known complication).
Differential Diagnosis List
Emphysematous cholecystitis with local perforation
Gallbladder carcinoma with perforation
Cholecystitis with choledochoduodenal fistula
Cholecystitis with choledochocolic fistula
Final Diagnosis
Emphysematous cholecystitis with local perforation
Case information
URL: https://www.eurorad.org/case/10390
DOI: 10.1594/EURORAD/CASE.10390
ISSN: 1563-4086