AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

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• Follow-up
• Miscellaneous
• Multimedia
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INTRODUCTION

Section 2 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Multimedia
• References

Background

Emphysematous cholecystitis is a rare variant of acute cholecystitis caused by infection of the gallbladder with gas-producing bacteria. Typically, the diagnosis is made by observing the presence of air within the gallbladder wall or lumen on plain abdominal radiographs. Emphysematous cholecystitis is associated with much higher rates of gangrene and perforation of the gallbladder and significantly increased rates of mortality compared to typical acute cholecystitis. Predisposing factors include male sex, advanced age, and diabetes.

Historical background

• 1901: Stotz first described emphysematous cholecystitis at autopsy.
• 1931: The first preoperative diagnosis is made using a plain abdominal radiograph.
• 1958: Fifty cases are described in the medical literature. A preponderance is noted in patients with diabetes and in elderly men. Clostridium is recognized as the most common pathogenic agent.
• 1994: Descriptions of successful laparoscopic management are reported.
• 2003: Computerized tomography is identified as the only imaging modality necessary to diagnose emphysematous cholecystitis (Bennett and Balthazar, 2003).
• 2005: Descriptions in the literature are still mostly individual case reports (Lallemand et al, 2005).

Pathophysiology

The bacteriology involves gas-producing organisms. The most common is Clostridium perfringens. Escherichia coli and anaerobic Streptococcus are less common. Gas is seen in the gallbladder lumen and wall and in pericholecystic tissues, in the absence of a biliary-enteric fistula. Approximately 30-50% of patients do not have gallbladder stones. Clostridial cholecystitis is associated with much higher rates of gangrene and perforation compared to simple acute cholecystitis.

The pathogenesis of gangrene involves thrombosis of the cystic artery in patients with an underlying atherosclerotic disease. This observation is supported by histopathologic reviews of specimens that reveal a much higher rate of endarteritis obliterans compared to simple acute cholecystitis. Development of emphysematous cholecystitis following hepatic artery embolization or endoscopic retrograde cholangiopancreatography also has been reported.

Frequency

International

Incidence is rare. Only 164 cases had been reported in the worldwide medical literature by 1971, but not all cases are reported.

Mortality/Morbidity

• Traditionally, it is considered a much more aggressive and lethal form of cholecystitis, with reported mortality rates of 15-25%.
• The current thinking has changed because imaging studies, such as ultrasound and CT scanning, allow earlier diagnosis. Mortality and morbidity may be lower, but this is an aggressive and potentially lethal disease.

Sex

• The male-to-female ratio for acute emphysematous cholecystitis is 3-5:1, unlike typical acute cholecystitis, which is 7 times more frequent in females than in males.

Age

• Unlike acute cholecystitis, acute emphysematous cholecystitis is a disease of elderly individuals.

CLINICAL

Section 3 of 11  

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• Clinical
• Differentials
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• Multimedia
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History

The clinical presentation of emphysematous cholecystitis is that of an especially severe form of biliary tract disease with severe symptoms and risk of cardiovascular collapse.

• The most common clinical complaints are right upper quadrant pain and fever.
• Nausea and vomiting occur less frequently, and patients may present with jaundice.
• Septic shock or peritonitis may occur as later clinical presentations.

Physical

• It is indistinguishable from acute cholecystitis.
• Common complaints include fever and right upper quadrant abdominal pain.
• Physical examination is significant for tenderness to palpation over the right upper abdomen at the McBurney point.
• Patients may be jaundiced.
• A patient with emphysematous cholecystitis is more likely to present with evidence of severe infection and with hemodynamic evidence of sepsis.

DIFFERENTIALS

Section 4 of 11  

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WORKUP

Section 5 of 11  

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• Follow-up
• Miscellaneous
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Lab Studies

• Leukocytosis usually is present but does not differentiate emphysematous cholecystitis from simple cholecystitis. Similarly, abnormalities of liver tests are not diagnostic of emphysematous cholecystitis.

Imaging Studies

• Abdominal radiograph
• • Classic findings include the presence of gas in the right upper quadrant outlining the gallbladder wall, an air-fluid level in the gallbladder lumen, or pericholecystic air. Pneumoperitoneum may be present but is rare.
  • Pneumobilia was noted in 15% of cases described by Garcia-Sancho Tellez (1999). Until recently, these radiologic findings were the only preoperative indication of emphysematous cholecystitis. This is because the clinical presentation is identical to simple acute cholecystitis.
  • Abdominal radiographs do not help identify all cases. Newer imaging modalities are more sensitive, and the entity is now being recognized more frequently.
• Ultrasound
• • This is the most common imaging modality employed to visualize the gallbladder.
  • Air can be visualized within the lumen and wall of the gallbladder.
  • It can help detect patients earlier than plain abdominal radiographs.
  • As described by Gill (1997), the characteristic findings include highly reflective echoes and a circular pattern of poorly marginated shadowing due to gas in the gallbladder wall.
  • Extensive gallbladder wall gas can be interpreted as nonvisualization of the gallbladder, resulting in false-negative results from the scans.
• CT scan of abdomen
• • This is a commonly used imaging modality that can detect emphysematous cholecystitis earlier than other diagnostic techniques.
  • It can help detect small amounts of air in the gallbladder wall that are missed by abdominal radiographs and ultrasound.
  • As described by Bennett and Balthazar in 2003, evaluation using abdominal CT scanning is now considered the primary imaging modality to help make the diagnosis, as this technique identifies emphysematous cholecystitis in cases where an ultrasound evaluation is equivocal. Initial use of CT scanning may eliminate the need for further imaging studies and facilitate appropriate clinical management.

Histologic Findings

Perforation and gangrene are noted more frequently than in simple acute cholecystitis (30-fold increase compared to simple acute cholecystitis). Obliteration of the cystic artery occurs secondary to endarteritis obliterans. Approximately 30-50% of cases are not associated with gallstones. Approximately 10% of cases have associated choledocholithiasis.

TREATMENT

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Medical Care

• Immediate surgery has been the standard of care since Hegner recognized the entity antemortem in 1931.
• Some reports of conservative management exist. Gill (1997) reported nonoperative management in 2 patients, using bowel rest, intravenous hydration, and antibiotics. One patient was alive and well 18 months later, while the second patient died of complications secondary to a cerebrovascular event.
• Percutaneous cholecystostomy with aggressive intravenous antibiotics and subsequent elective cholecystectomy also have been reported.
• Rapid surgical cholecystectomy is still the standard of care.

Surgical Care

• Open cholecystectomy: Traditionally, early open cholecystectomy was performed because of risk of death from sepsis. This surgical procedure was performed because of the observation that septic shock and death progressed quickly in this disease, especially in the elderly and diabetic populations who are most at risk for emphysematous cholecystitis.
• Laparoscopic cholecystectomy
• • Successful management of 3 patients using laparoscopic cholecystectomy has been described by Banwell (1994).
  • The diagnosis in all 3 cases was made using ultrasound rather than plain abdominal radiographs.
  • The postoperative course was complicated by wound infections in 2 patients, and the mean hospital stay was 6 days (due to the need for intravenous antibiotics postoperatively).
• Outcome
• • While Gill (1997) had no deaths in his series of 8 patients, Garcia-Sancho Tellez (1999) reported on 20 patients reviewed retrospectively, and his findings agreed with earlier publications regarding the virulence of this subtype of acute cholecystitis. He reported a 25% mortality rate and a 50% morbidity rate.
  • As in other studies, the majority of patients were elderly, male, and diabetic. Immunosuppression also may be a factor.
  • Three patients presented with septic shock, 7 were jaundiced, and 8 had frank peritonitis.
  • The diagnosis of emphysematous cholecystitis was made by abdominal radiograph or ultrasound.
  • All patients underwent urgent cholecystectomy; 8 had associated pericholecystic abscesses, 7 had gangrene, and 3 had bile peritonitis.
  • The authors continue to recommend immediate surgery for this disease.
  • This disease is rare enough that case reports describing the diagnosis and management still appear in the general surgical literature (Chiu et al, 2004; Lallemand et al, 2003).

MEDICATION

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Patients should be treated with IV antibiotics effective against clostridial species and the more common gram-negative aerobic species associated with acute cholecystitis. A good choice is ampicillin/sulbactam (Unasyn) used alone or in combination with metronidazole (Flagyl).

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

FOLLOW-UP

Section 8 of 11  

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Further Inpatient Care

• Institute standard postoperative care after cholecystectomy, using antibiotics active against anaerobic bacilli.
• Bacteriologic samples obtained during the surgical procedure can also help guide antibiotic management.

Complications

• The most feared complication is potentially lethal septic shock.

Prognosis

• No unfavorable long-term sequelae develop if treated successfully.

MISCELLANEOUS

Section 9 of 11  

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• Medication
• Follow-up
• Miscellaneous
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Medical/Legal Pitfalls

• As with any surgical disease, delay in diagnosis or treatment and intraoperative misadventures

MULTIMEDIA

Section 10 of 11  

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• Miscellaneous
• Multimedia
• References

Media file 1:  Plain abdominal radiograph showing air in the gallbladder.
	View Full Size Image
Media type:  X-RAY

Media file 2:  CT scan of a patient with emphysematous cholecystitis showing an air-fluid level in the gallbladder as well as air in the gallbladder wall.
	View Full Size Image
Media type:  CT

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
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• Follow-up
• Miscellaneous
• Multimedia
• References

• Banwell PE, Hill AD, Menzies-Gow N. Laparoscopic cholecystectomy: safe and feasible in emphysematous cholecystitis. Surg Laparosc Endosc. Jun 1994;4(3):189-91. [Medline].
• Bennett GL, Balthazar EJ. Ultrasound and CT evaluation of emergent gallbladder pathology. Radiol Clinics of North America. 2003;41:1203-1216. [Medline].
• Chiu HH, Chen CM, Lo MR. Emphysematous cholecystitis. Amer J Surg. 2004;188:325-326. [Medline].
• Garcia-Sancho Tellez L, Rodriguez-Montes JA, Fernandez de Lis S. Acute emphysematous cholecystitis. Report of twenty cases. Hepatogastroenterology. Jul-Aug 1999;46(28):2144-8. [Medline].
• Gill KS, Chapman AH, Weston MJ. The changing face of emphysematous cholecystitis. Br J Radiol. Oct 1997;70(838):986-91. [Medline].
• Hegner CF. Gaseous pericholecystitis with cholecystitis and cholelithiasis. Arch Surg. 1931;22:993-1000.
• Lallemand B, De Keuleneer R, Maassarani F. Emphysematous cholecystitis. Acta Chir Belg. 2003;103:230-232. [Medline].
• Lindsey I, Kitchen G, Leung D. Emphysematous cholecystitis. Aust N Z J Surg. Apr 1996;66(4):267-8. [Medline].

Article Last Updated: Jan 22, 2006