Abstract
This instance of gaseous cholecystitis is reported to illustrate the value of roentgenography in what appeared at first to be an uncomplicated choledocholithiasis. The patient, a 50-year-old white butcher, entered the hospital in January 1947. He had been in excellent health until the age of 52, when a mild diabetes mellitus developed, which was controlled by diet. In mid 1945, an attack of mild aching in the right upper quadrant of the abdomen occurred , without nausea or jaundice. The attack lasted for one day. There was no history of an idiosyncrasy to fried or fatty foods. On Jan. 18, 1947, about four hours after a roast pork dinner, the patient experienced a severe, steady, non-radiating pain in the right upper quadrant of the abdomen, with no nausea, vomiting, or chills. The pain subsided during the night, but a dull ache persisted. Two days later (Jan. 20), the patient was awakened at five o'clock in the morning by a recurrenee of severe right upper quadrant pain, which continued with diminishing intensity throughout the day. He ate alight lunch and supper and that night vomited bile. He also noticed that his urine was dark and foul and that his stool was black. He was seen by a physician and given morphine for relief of pain. A dull ache continued, however, and on Jan. 22, four days after the initial attack, he was again awakened early in the morning by severe right upper quadrant pain. He was seen that morning by his physician, who noted the presence of jaundice. The patient felt somewhat better during the next three days but the jaundice and right upper quadrant ache persisted. He entered the hospital for study on Jan. 26, 1947. The physical examination on admission revealed a moderate icterus. The liver was barely palpable and slightly tender to percussion. There was a sense of resistance in the right upper quadrant of the abdomen with slight tenderness in that area. No other abnormalities were noted. The temperature ranged between 100 and 102° F. Laboratory examinations revealed a slight elevation of globulin (3.9 gm. per cent) with normal albumin. The cephalin flocculation test was four plus. The thymol turbidity was within normal limits. The alkaline phosphatase was elevated, its highest level being W.O Bodansky units. The prothrombin time was slightly elevated. The van den Bergh reaction was prompt, with a reading of 14.8 mg. percent. The white blood count and differential count were normal. The red blood count was 4,800,000 on admission but this figure subsequently dropped to 3,800,000. Roentgen examination of the upper gastro-intestinal tract on Jan. 28, with contrast material, showed rather marked spasm of the prepyloric portion of the stomach, but no intrinsic lesion was demonstrated. During a review of the films on the following day, a persistent, rounded gas shadow was observed in the gallbladder area.
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