S1537 A Case of Gangrenous Cholecystitis Without Acute Cholecystitis

Abstract

Introduction: Gangrenous cholecystitis (GC) is a serious and the most common complication of acute cholecystitis. We present a case of an incidental finding of GC with negative clinical findings and lab parameters of acute cholecystitis. Case Description/Methods: The patient is an 82 year old female, PMH of obesity hypoventilation syndrome (OHS), hypertension, hyperlipidemia, who presented to the pulmonology clinic for follow-up. Her pulmonary function test (PFT) was pertinent for a non-obstructive pattern with normal lung volumes, and severe diffusion defect. Echocardiography and CT PE protocol was ordered to assess for any pulmonary hypertension, thromboembolic disease, and to rule out interstitial lung disease. Incidentally, the patient was found to have multiple air foci throughout GB on CT, but no PE was identified. The patient deferred hospitalization and pursued outpatient workup with basic labs, MRCP, and general surgery referral. MRCP revealed common bile duct dilation, cholelithiasis, and choledocholithiasis. Within the next ten days, the patient developed sudden onset chest pain, nausea, vomiting, and increased shortness of breath without fevers, chills, or diaphoresis. Serial troponin and EKG were negative. Bilirubin was mildly elevated at 1.1, and she had no leukocytosis, hypotension, or confusion. Ultrasound (USG) abdomen showed cholelithiasis without evidence of acute cholecystitis. She was admitted, started on antibiotics, and underwent ERCP for stone removal and biliary sphincterotomy. She also underwent laparoscopic cholecystectomy with drain placement, and acute on chronic severe gangrenous cholecystitis was noted. Discussion: GC is the final stage of gall bladder (GB) inflammation, characterized by necrosis of the GB wall secondary to ischemia due to progressive vascular insufficiency. GC carries a high mortality rate compared to acute cholecystitis and can lead to deadly complications of GB perforation, abscess formation, and peritonitis. Patients usually have the clinical findings of acute cholecystitis (right upper quadrant pain, fever), elevated WBC count, elevated liver enzymes, USG abdomen finding of inflammation and thickening of GB wall. Imaging findings specific for GC are CT finding of gas in the wall or lumen, intra-luminal membranes, an irregular wall, and pericholecystic abscess. The lack of the findings mentioned above makes our case rare and challenging. Diagnosis and surgical treatment of GC before complication is essential to avoid high morbidity and mortality.