Sonographic Non-Visualization of the Gallbladder: A Pitfall in Diagnosis of Emphysematous Cholecystitis

Zaw Min

doi:10.21767/2471-8041.100041

Abstract

Emphysematous cholecystitis is an uncommon complication of calculous cholecystitis due to secondary infection of gallbladder wall with gas-forming enteric organisms. It carries high morbidity and mortality to the patients and a rapid and early diagnosis is essential in patient’s clinical outcomes. Ultrasonography is usually the first and foremost test performed in cases of suspected biliary diseases. Herein, we describe a diagnostic pitfall of ultrasound in a patient with emphysematous cholecystitis – non-visualization of gallbladder, caused by reverberations from air in the gallbladder wall.

Highlights

Emphysematous cholecystitis is rare clinical sequelae of acute cholecystitis
Sonographic finding, highly suggestive of emphysematous cholecysitis, is known as the effervescent gallbladder in which multiple echogenic foci rising from the bottom to the top within the gallbladder resembling champagne gas bubbles [2]
A high clinical index of suspicion of emphysematous cholecystitis should be raised in an appropriate clinical setting if the ultrasound reported “nonvisualization” or “obscured” gallbladder because the entire gallbladder wall could be filled with gas, obscuring visualization of the gallbladder

Summary

Introduction

Emphysematous cholecystitis is rare clinical sequelae of acute cholecystitis. A high mortality (15%) was documented in cases of emphysematous cholecystitis [1]. Given persistent fever and abdomen pain, computed tomography (CT) of abdomen was performed It demonstrated foci of air pockets within the gallbladder wall and a gallstone (Figure 1), suggestive of emphysematous cholecystitis. When a layer of the gas within the gallbladder wall is circled around the gallbladder, it usually obscures the visualization of gallbladder on the ultrasound, resulting in reporting of “non-visualized gallbladder”, which could be disregarded by clinicians In this case, computed tomography is very helpful and becomes a diagnostic modality of choice for complicated cholecystitis [4,5,6]. While ultrasound report documents visualization of the gallbladder is obscured by gas, a high index of clinical suspicion is required for diagnosis of emphysematous cholecystitis in appropriate clinical context

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Discussion