A 49-year-old man presented to the emergency department with a 2-day history of nausea, anorexia, and abdominall, chest, and scapular pain.
Prepared by Anthony G. Smith, MD, Department of Surgery,
Margaret A. Miller, MD, Department of Radiology, and Kurt R.
Stahlfeld, MD, FACS, Program Director, Department of Surgery,
Mercy Hospital of Pittsburgh, Pittsburgh, PA.
A 49-year-old man presented to the emergency department with a
2-day history of nausea, anorexia, and abdominal, chest, and
scapular pain. He denied any vomiting. His medical history was
significant for type-2 diabetes, obesity, deep venous thrombosis,
and a prior appendectomy. On physical examination, the patient had
right upper quadrant tenderness, mild abdominal distention, but no
peritoneal signs. White blood cell count was 23,000 and total
bilirubin was 1.6. Abdominal plain films (Figure 1) and an
ultrasound (Figure 2) were performed.
Abdominal radiography showed an abnormal round collection of air
in the right upper quadrant. This was believed to be intraluminal
gas in the gallbladder. Abdominal ultrasound showed curvilinear
echogenic foci involving the gallbladder wall with posterior
acoustic shadowing. Findings from both studies were thought to be
consistent with emphysematous cholecystitis.
The patient underwent emergent cholecystectomy. Approximately
300 to 500 mL of air was aspirated from the gallbladder.
Intraoperative cholangiography was normal. Cultures of the bile
, and the patient was started on ampicillin-sulbactam. The
patient's postoperative course was uneventful and he was discharged
to home on postoperative day 3.
Acute emphysematous cholecystitis represents approximately 1% of
all cases of cholecystitis. The pathognomonic sign is gas in the
lumen and wall of the gallbladder.
The average age of patients is 60 years.
As opposed to typical acute cholecystitis, approximately 75% of
cases occur in men.
Forty percent of cases involve diabetic patients.
The usual presentation is abrupt onset of right upper quadrant
pain, accompanied by nausea and vomiting. Patients may become toxic
Gas in the wall and lumen of the gallbladder on plain abdominal
radiograph is pathognomonic of emphysematous cholecystitis.
The gas is produced by the bacteria
Frequently the infection is polymicrobial.
is present in half the reported cases. High-dose intravenous
antibiotics should be administered early in the patient's course.
Usually the gallbladder is gangrenous at the time of operation.
Stones are absent in approximately 30% of cases. Appropriate
treatment is early emergent cholecystectomy.
As the incidence of gangrene and free perforation is 40% to 60%,
laparoscopic cholecystectomy is challenging, with conversion rates
approaching 50%. Mortality is high, given the high incidence of
gangrene and perforation of the gallbladder.