Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 68, Num. 3, 2006, pp. 165-166

Indian Journal of Surgery, Vol. 68, No. 3, May-June, 2006, pp. 165-166

Images in Surgery

Emphysematous cholecystitis

Shamimi Kourosh, Aminian Ali, Moazami Fereydon, Jalali Mehdi, Darabnia Jamshid

Department of General Surgery, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran
Correspondence Address:Ali Aminian, Department of General Surgery, Imam Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran. E-mail: aliaminian@doctor.com

Code Number: is06046

A 62-year-old diabetic lady was admitted because of right upper quadrant pain, fever and jaundice. Following initiation of medical management including antibiotic therapy, endoscopic sphincterotomy was done with impression of acute cholangitis. However, her general condition became worse during the next 36 h. Plain abdominal film showed air in the right upper quadrant [Figure - 1]. Computed tomography demonstrated air-fluid level in the lumen of gallbladder and gas within the gallbladder wall [Figure - 2]. With diagnosis of emphysematous cholecystitis, emergency cholecystectomy was done. Klebsiella was isolated from bile culture. Postoperative course was complicated with sepsis and subsequent multiple organ failure. With aggressive supportive care in ICU, she was finally discharged after 2 months.

Emphysematous cholecystitis is an uncommon but life-threatening form of acute cholecystitis caused by the presence of gas-forming organisms in the gallbladder, such as Clostridia species, Escherichia coli, Klebsiella species and anaerobic streptococci. Emphysematous cholecystitis frequently affects elderly men and it is usually associated with diabetes mellitus. The risk of gangrene and perforation of the gallbladder is relatively high for patients with emphysematous cholecystitis and the mortality rate is 15%, as compared with 4% for acute cholecystitis. The etiology of emphysematous cholecystitis is controversial, but it is considered to be due to ischemia of the gallbladder from primary vascular compromise, with secondary proliferation of gas-producing bacteria.[1]

The diagnosis of emphysematous cholecystitis based on the demonstration of varying amounts of gas in the gallbladder lumen and wall and occasionally in the bile ducts or pericholecystic area, can be made from plain abdominal radiography, ultrasonography or more accurately by computed tomography scan. Prompt diagnosis is essential, as early intervention can minimize the serious morbidity and mortality rates associated with emphysematous cholecystitis.[1]

Emergency cholecystectomy is needed in most cases due to the high incidence of complications, but percutaneous drainage of gallbladder is an alternative option for patients unfit for surgery.[2] Based on clinical assessment, conservative surgical management is also possible in milder form of disease.[1],[3]

References

Copyright 2006 - Indian Journal of Surgery

The following images related to this document are available:

Photo images