Teaching Case

A 64 year-old diabetic male patient referred with right hypochondrial pain, fever of around 38.5 °C, and vomiting for the last 48 hours. His white blood cell (WBC) count was found to be high (9800/ml).

A 64 year-old diabetic male patient referred with right hypochondrial pain, fever of around 38.5 °C, and vomiting for the last 48 hours. His white blood cell (WBC) count was found to be high ( 9800/ml). Plain abdominal X-ray film was not meaningful due to excessive intestinal gas, and sonographic examination could not be performed due to severe pain. A computed tomography (CT) examination of the abdomen was performed, revealing gas within the gall bladder wall and lumen, associated with pericystic, perihepatic and periflexural fluid collection. An emergency cholecystectomy was performed upon CT findings, and post-surgical findings were the same as CT findings.

Acute emphysematous cholecystitis (AEC) is a variant of acute cholecystitis, first described at autopsy in 1901 by Stolz and radiographically in 1931 by Hegner. It is characterized by the presence of gas in the gall bladder lumen, wall or pericholecystic tissues in the absence of an abnormal communication between the biliary system and the gastrointestinal tract, due to gas-producing microorganisms. The etiology of AEC is calculous obstruction of the cystic duct with inflammatory edema in 70 to 80 % of the cases, and acalculous obstruction in the rest of the cases, leading to cystic artery occlusion. The most frequent pathogenic microorganisms are c. perfringens, c. welchii, e. coli, b. fragilis, anaerobic staphylococci and streptococci. Diabetes mellitus and other debilitating diseases are predisposing factors. Most of the patients are more than 50 years-old. Males are affected more than females in a ratio of 5 to 1. Clinical findings are right hypochondrial pain, fever, vomiting, jaundice, peritonitis¸ and laboratory findings are high WBC count in more than 2/3 of the patients, and hyperbilirubinemia. Plain abdominal X-ray films reveal air-fluid level in gall bladder lumen and/or air in gall bladder wall, and rarely pneumobilia. Sonographic pictures show high-level echoes with distal reverberations and a circular pattern of poorly marginated shadowing typical of gas in the gall bladder fossa outlining the gall bladder wall. Plain abdominal X-rays and sonography leads to diagnosis in almost 95 % of the cases. Computed tomography (CT) findings are highly characteristic with almost 100 % sensitivity, demonstrating gas in the gall bladder lumen (stage 1), in the gall bladder wall (stage 2), or pericholecystic tissues (stage 3). Excess distension of gall bladder can result in leakage of gas across the intact mucosa and through the areas of deficiency in the muscle wall, such as along the cystic duct. Gas may then spread into perimuscular layers, collect under serosa and even rarely rupture into the peritoneal cavity. Complications of AEC can be listed as gangrene in 75 % of the cases, and gall bladder perforation in 20 % of the cases. The apparently high mortality (around 25 %) and morbidity (around 50 %) rates associated with AEC emphasizes the importance of emergency cholecystectomy.