Case Report

Abstract

Purpose: We present a case of emphysematous cholecystitis diagnosed with the aid of a CT scan with PO and IV contrast. Methods: Review of patient chart Results: 84 y/o male admitted to an outside hospital with nausea, vomiting, abdominal pain, and diarrhea. A CT scan was performed with PO and IV contrast during this admission that showed air/fluid levels in the gallbladder and a small bowel obstruction with a transition point in the pelvis. At the family's request the patient was transferred to WPH on hospital day# 4. At this time, the patient was no longer nauseated. His physical exam was within normal limits except for his abdominal exam, which was soft, mildly distended, (−) Murphy's sign, and non-tender throughout. Laboratory values were within normal limits except for an elevated white blood cell count –12.5 with 10% bands. On admission to WPH the patient was treated for a suspected gallstone ileus with conservative measures – NG tube decompression, NPO status, IVF resuscitation. The next day the patient was taken to the OR for a diagnostic laparascopy, which showed a heavily inflamed gallbladder with many adhesions. It was deemed safest for the patient to close and consult Interventional Radiology for placement of a percutaneous cholecystostomy tube with aspiration and culture and sensitivities of gallbladder contents, which was performed later that afternoon. The patient was subsequently transferred to the SICU with Zosyn 4.5 Grams IV Q6 until the culture was identified. On POD # 1 gram negative and gram positive rods were isolated in the anaerobic bottle – Infectious Disease was consulted, Clindamycin 900 mg IV Q6 was added and Zosyn was changed to Q8 and a PICC line was placed for possible long term need for TPN and IV access. POD #2 – Clostridium Perfringens was identified, the infectious disease consultants elected to keep the patient on the current antibiotic regimen. The patient had an increasing WBC count, peaking on POD# 3 at 25.4 and 89% neutrophils. However, he remained afebrile post-operatively. The patient continued to improve slowly and on POD# 5 he was transferred to the step-down unit at which time he had a large, somewhat bloody bowel movement. The following day, his NG tube and foley catheter were removed, a clear liquid diet was started, and the patient was encouraged to ambulate with assistance. On POD# 7 the clindamycin was stopped secondary to concerns for Clostridium Difficile colitis and he was started on a full liquid diet. On POD# 9, the patient was tolerating a regular diet, ambulating well on his own, and was deemed stable for transfer to the rehabilitation unit in the hospital. Conclusion: The patient was deemed stable for transfer to the rehabilitation unit in the hospital.