Gangrenous Cholecystitis with Atypical Presentation in an Elderly Diabetic Woman

Vera Clérigo,André Rodrigues,Dora Sargento,Glória Silva,Lígia Fernandes,Cláudia Rocha

doi:10.4236/crcm.2014.39110

Abstract

In elderly patients, numerous factors subsidize the diagnostic challenge and high incidence of complications in this specific population, taking gangrenous cholecystitis as a critical example. The aim of this work is to report an unusual case of gangrenous choleystitis in an elderly diabetic women and its atypical clinical presentation. A 79-year-old female patient came to our observation; her medical history showed nausea and vomiting of about 2 hours which rapidly ended with symptomatic therapy, without recurrence, and a 3-week history of intermittent fever associated with productive cough. No abdominal discomfort was declared. Physical examination of the abdomen was negative. Laboratory analysis revealed leukocytosis with the remaining criteria within the normal range. After 2 days, she started with a mildabdominal pain in the epigastric region that rapidly progressed to the right upper quadrant, right flank and right iliac fossa, without nausea, vomiting or fever. Abdominal computer tomography findings revealed thickness of the gall-bladder and important densification of the vascular bed. Acute cholecystitis was diagnosed. The patient was then submitted to a laparoscopic cholecystectomy under general anaesthesia with findings suggestive of gangrenous acute cholecystitis confirmed by histologic examination of the specimen. Delays in diagnosing acute cholecystitis in specific populations, such as elderly diabetics, result in a higher prevalence of morbidity and mortality due to potentially serious complications as gangrenous cholecystitis. Consequently, the diagnosis should be measured and investigated promptly in order to prevent poor outcomes.

Highlights

Gangrenous cholecystitis (GC) is considered as a severe complication and contemplates a minority of all patients presenting with acute cholecystitis [1]-[3]
Due to the described factors, many elderly patients are misdiagnosed with relatively benign conditions and are at greater risk of being admitted to the wrong service
Acute cholecystitis is a critical example of how the previous factors are likely to play an important role in the progression towards complications as gangrenous cholecystitis

Summary

Introduction

Gangrenous cholecystitis (GC) is considered as a severe complication and contemplates a minority of all patients presenting with acute cholecystitis [1]-[3]. Vascular compromise secondary to epithelial injury due to sustained obstruction of the cystic duct is a critical mechanism. Due to epithelial injury, phospholipases are released and degrade adjacent cell membranes generating an important inflammatory reaction [4] [5]. The risk factors for this condition and its influence on morbidity and mortality paralleled with those of non-gangrenous acute cholecystitis (NGAC) are not consistently defined in several studies. It commonly occurs in older and diabetic patients [1] the pre-operative diagnosis of this condition may denote a clinical challenge. The aim of this work is to report on a gangrenous cholecysitis in an elderly diabetic woman, causing a very atypical clinical picture and draw attention to the problematic diagnoses in elderly diabetic populations in particular

Case Report

Discussion

Findings

Conclusion