Emphysematous Cholecystitis

 

• Caused by gas-forming organism
  • In about 1/3 = clostridium perfringens
  • Also E. Coli and Klelbsiella
• Occurs more often in men
  • As opposed to gallbladder disease in general which occurs more often in women
• Mostly elderly patients (>60) with diabetes
• Vascular compromise of the cystic artery may play a role in the etiology
• Clinical findings
  • As with cholecystitis, right upper quadrant (RUQ) pain and tenderness
  • Leukocytosis
  • Jaundice is rare
• Gas may occur in the wall and/or the lumen
  • May spread to pericholecystic tissue
  • Rarely, gas may escape into the bile ducts
    • This is rare since cystic duct is usually occluded in cholecystitis
• Plain film findings
  • May show air in the wall or lumen
• US findings    
  • Indistinct shadowing emanating from wall or lumen of gallbladder
• CT findings of (non-complicated) cholecystitis
  • Most common is gallbladder wall thickening >3mm, and
  • Cholelithiasis
  • Increased density of bile (>20 H)
  • Loss of clear definition of gallbladder wall
  • Pericholecystic fluid such as a halo of edema

Emphysematous cholecystitis-red arrow points to air in lumen of gallbladder; green arrow
points to thickened gallbladder wall; blue arrow points to pericholecystic stranding;
yellow arrow points to pericholecystic fluid
Click here for same photo without arrows

• Treatment
  • Preoperative Percutaneous drainage
  • Emergency cholecystectomy
    • Surgical mortality of 15-25%
• Complications
  • Fivefold increase in perforation than uncomplicated acute cholecystitis
• Perforation of the gallbladder
  • Frequency is declining because of earlier diagnosis of acute cholecystitis
  • Diagnosis
    • Pre-perforation plain film showing stones clustered in gallbladder may subsequently show stones scattered in RUQ after perforation
    • Pericholecystic fluid collection on CT or US (not-specific)
    • Scintography may show radiotracer outside of gallbladder in Morrison’s pouch or flank
  • Treatment
    • Preoperative percutaneous drainage of gallbladder and biloma
    • Emergency surgery

  

• Gore, R. and Levine, M: textbook of Gastrointestinal; Radiology, W.B. Saunders, 2000.
• Moss, A., Gamsu, G. and Genant, H.: Computed Tomography of the Body. W.B. Saunders,1992.
• Bloom, A. and Remy, P.: eMedicine; Emphysematous Cholecystitis