Figure 1
Abdominal plain film
Abdominal plain film showing a distended gallbladder, with air in its wall. A fluid-air level is also clearly seen.
Emphysematous cholecystitis
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsIvo Ferreira, Inês Bessa, Carlos Macedo, Paulo Soares, Manuela Certo
Connected authors
85 years, female
Clinical History
An 85-year-old woman came to our emergency department with a two-day history of fever, anorexia, nausea and hypotension.
She had a previous history of metabolic syndrome (diabetes mellitus, hypertension and dyslipidaemia).
At physical examination the upper right quadrant of the abdomen revealed tenderness and at deep palpation a “mass” was noted.
She had a previous history of metabolic syndrome (diabetes mellitus, hypertension and dyslipidaemia).
At physical examination the upper right quadrant of the abdomen revealed tenderness and at deep palpation a “mass” was noted.
Imaging Findings
The plain film of the abdomen (Fig. 1) show marked distention of the gallbladder and air fluid level with gas in the gallbladder wall. CT (Fig. 2) confirmed the plain film findings, depicting the extension of the inflammatory process.
Our patient was submitted to surgery and was treated with antibiotic therapy (piperacillin/tazobactam). She fully recovered and was discharged 3 weeks after surgery.
Our patient was submitted to surgery and was treated with antibiotic therapy (piperacillin/tazobactam). She fully recovered and was discharged 3 weeks after surgery.
Discussion
Acute emphysematous cholecystitis is a less frequent form of acute cholecystitis, with the presence of gas within the wall, lumen of the gallbladder or biliary ducts as main landmark. [1] The presence of gas is due to gallbladder wall ischaemia and overgrowth of gas-producing bacteria, most frequently Clostridium species. [2]
It is most frequent in diabetic patients and in men. [3] Emphysematous cholecystitis may occur in patients without gall stones, like in our patient.
The typical clinical presentation is similar to the one that our patient presented, most commonly: right upper quadrant pain, fever, nausea and vomiting. [4]
Plain film can be enough for the diagnosis, which show a distended gallbladder with gas within its wall. However, they can be normal in some patients. [5] Other imaging techniques, particularly CT, can be very helpful as it can confirm the diagnosis and evaluate the extension of the inflammatory changes.
Surgery is the preferred treatment approach. Mortality rate is much higher than for common cholecystitis, and can be as high as 25%. [2]
It is most frequent in diabetic patients and in men. [3] Emphysematous cholecystitis may occur in patients without gall stones, like in our patient.
The typical clinical presentation is similar to the one that our patient presented, most commonly: right upper quadrant pain, fever, nausea and vomiting. [4]
Plain film can be enough for the diagnosis, which show a distended gallbladder with gas within its wall. However, they can be normal in some patients. [5] Other imaging techniques, particularly CT, can be very helpful as it can confirm the diagnosis and evaluate the extension of the inflammatory changes.
Surgery is the preferred treatment approach. Mortality rate is much higher than for common cholecystitis, and can be as high as 25%. [2]
Differential Diagnosis List
Emphysematous cholecystitis
Emphysematous cholecystitis
Cholecysto-enteric fistula
Final Diagnosis
Emphysematous cholecystitis
References
[1] Lorenz RW, Steffen HM (1990) Emphysematous cholecystitis: diagnostic problems and differential diagnosis of gallbladder gas accumulations. Hepatogastroenterology 37 Suppl 2:103-6 (PMID: 2083919)
[2] Garcia-Sancho Tellez L, Rodriguez-Montes JA, Fernandez de Lis S, Garcia-Sancho Martin L (1999) Acute emphysematous cholecystitis. Report of twenty cases. Hepatogastroenterology 46(28):2144-8 (PMID: 10521957)
[3] Carvalho HP, Mulero HL, Jackiw NM (1965) Emphysematous cholecystitis in diabetic patients. JAMA 194(5):561-3 (PMID: 5897372)
[4] Shrestha Y, Trottier S (2007) Images in clinical medicine. Emphysematous cholecystitis. N Engl J Med 20;357(12):1238 (PMID: 17881755)
[5] Gill KS, Chapman AH, Weston MJ (1997) The changing face of emphysematous cholecystitis. British Journal of Radiology 70:986-991 (PMID: 9404199)
Case information
| URL: | https://www.eurorad.org/case/12103 |
| DOI: | 10.1594/EURORAD/CASE.12103 |
| ISSN: | 1563-4086 |
Figure 2
Post-contrast CT
Post-contrast CT image in the axial plane, showing air in gallbladder wall, with a fluid-air level. Note the inflammatory changes surrounding the gallbladder.
Abdominal plain film
Abdominal plain film showing a distended gallbladder, with air in its wall. A fluid-air level is also clearly seen.
Ferreira I, Department of Radiology, Centro Hospitalar do Porto, Portugal
Ferreira I, Department of Radiology, Centro Hospitalar do Porto, Portugal
Post-contrast CT
Post-contrast CT image in the axial plane, showing air in gallbladder wall, with a fluid-air level. Note the inflammatory changes surrounding the gallbladder.
Ferreira I, Department of Radiology, Centro Hospitalar do Porto, Portugal
Ferreira I, Department of Radiology, Centro Hospitalar do Porto, Portugal