Diagnosis

Abstract

The diagnosis was emphysematous cholecystitis (note the air-fluid level in the lumen of the gallbladder with a gaseous ring in its wall on the radiograph).Emphysematous cholecystitis is an uncommon but life-threatening variant of acute cholecystitis that requires early recognition and prompt surgical intervention. There is a male predominance and approximately 35% of cases occur in diabetic patients.1Joshi N. Caputo G.M. Weitekamp M.R. et al.Infections in patients with diabetes mellitus.N Engl J Med. 1999; 341: 1906-1912Crossref PubMed Scopus (758) Google ScholarClostridium perfringens, E. coli, and Klebsiella are the most common gas-forming bacteria that cause the disease. It is diagnosed by radiographic demonstration of gas bubbles within the gallbladder wall or lumen on plain films, and frequently is complicated by gallbladder gangrene or perforation.2Grayson D.E. Abbott R.M. Levy A.D. et al.Emphysematous infections of the abdomen and pelvis: a pictorial review.Radiographics. 2002; 22: 543-561Crossref PubMed Scopus (236) Google Scholar Clinical presentation and physical findings may be similar to acute cholecystitis, but mortality is substantially higher in the emphysematous infection. All diabetic patients with symptoms of acute cholecystitis should have a plain radiograph of the abdomen to search for emphysema. The treatment of choice is rapid surgical removal of the gallbladder, in addition to broad-spectrum antibiotic therapy.In our patient, emergency cholecystectomy was performed and E. coli was isolated from the bile culture. He had an uneventful postoperative recovery. The diagnosis was emphysematous cholecystitis (note the air-fluid level in the lumen of the gallbladder with a gaseous ring in its wall on the radiograph). Emphysematous cholecystitis is an uncommon but life-threatening variant of acute cholecystitis that requires early recognition and prompt surgical intervention. There is a male predominance and approximately 35% of cases occur in diabetic patients.1Joshi N. Caputo G.M. Weitekamp M.R. et al.Infections in patients with diabetes mellitus.N Engl J Med. 1999; 341: 1906-1912Crossref PubMed Scopus (758) Google ScholarClostridium perfringens, E. coli, and Klebsiella are the most common gas-forming bacteria that cause the disease. It is diagnosed by radiographic demonstration of gas bubbles within the gallbladder wall or lumen on plain films, and frequently is complicated by gallbladder gangrene or perforation.2Grayson D.E. Abbott R.M. Levy A.D. et al.Emphysematous infections of the abdomen and pelvis: a pictorial review.Radiographics. 2002; 22: 543-561Crossref PubMed Scopus (236) Google Scholar Clinical presentation and physical findings may be similar to acute cholecystitis, but mortality is substantially higher in the emphysematous infection. All diabetic patients with symptoms of acute cholecystitis should have a plain radiograph of the abdomen to search for emphysema. The treatment of choice is rapid surgical removal of the gallbladder, in addition to broad-spectrum antibiotic therapy. In our patient, emergency cholecystectomy was performed and E. coli was isolated from the bile culture. He had an uneventful postoperative recovery.