AB161. 182. Emphysematous cholecystitis: case report on a rare, life threatening presentation

Abstract

: A 78-year-old gentleman with type 2 diabetes mellitus, atrial fibrillation, chronic kidney disease and hypertension presented to the emergency department with sudden onset of severe right upper quadrant with associated vomiting. White cell count showed a leukocytosis of 24×10×9/L and a C-reactive protein of 57 mg/L. An ultrasound abdomen revealed no acute gallbladder or biliary pathology. Computed tomography of the abdomen revealed pericholecystic fat stranding, an air-liquid level within the gallbladder and gas dissecting along a significant portion of the gallbladder wall—findings consistent with emphysematous cholecystitis, grade 3 with associated perforation and small volume of portal venous gas. Our patient underwent an emergency laparotomy with cholecystectomy. Pathology examination revealed acute acalculous gangrenous cholecystitis. Our patient required a 5-day admission to intensive care unit post-operatively. Emphysematous cholecystitis was first described at autopsy in 1901 by Stolz, who characterized emphysematous cholecystitis by the presence of air within the gallbladder and/or the biliary tree in the absence of an abnormal communication between the biliary system and the gastrointestinal tract. Emphysematous cholecystitis is a potentially life-threatening anaerobic infection, is a variant of acute cholecystitis. The mortality rate for acute emphysematous cholecystitis however is 15–50%. Despite the high mortality associated with gangrene and gallbladder perforation, patients with emphysematous cholecystitis do not exhibit alarming clinical signs of sepsis, and the presenting symptoms are often nonspecific and initially indistinguishable from those of uncomplicated acute cholecystitis. Patients with diabetic neuropathy may not experience typical right upper quadrant pain and maybe present with a paucity of symptoms.