Acute Emphysematous Cholecystitis Research Articles

Pathologic examination of ectopic pancreatic tissue in the gallbladder: A case report

Abstract Introduction/Objective Ectopic pancreatic tissue (EPT) is an entity defined by the presence of pancreatic tissue at its non-physiological site, while co-existing with original tissue in its correct anatomical location. While EPT is a rare process in locations such as the stomach, duodenum, and esophagus; it is even more uncommon for it to occur in the gallbladder. To our knowledge, fewer than thirty cases of EPT in the gallbladder have been reported. The following case report presents a 47-year-old woman with ectopic pancreatic tissue in the gallbladder. Methods/Case Report A 47-year-old female presented to our emergency department with her third episode of colicky right upper quadrant pain. Ultrasound imaging demonstrated cholelithiasis with additional ill-defined findings of the gallbladder wall, which included but were not limited to acute emphysematous cholecystitis and chronic cholecystitis with features of porcelain gallbladder. Laparoscopic cholecystectomy was performed without complications. Pathologic evaluation of the specimen demonstrated a cystic structure at the fundus of the gallbladder with coexisting EPT, fundic-type adenomyomatosis, and cholelithiasis. Results (if a Case Study enter NA) NA Conclusion Ectopic pancreatic tissue is a rare incidental finding which is often confused for a malignant process. While it is more commonly seen in the gastrointestinal tract from the esophagus to the duodenum, it can present in other sites such as in this case. Currently, there is no specific imaging method to determine the presence of EPT. Ultrasonography is nonspecific and EPT can be confused for a number of conditions ranging from benign to malignant. Gross examination is fairly unremarkable, however microscopic examination is a straightforward diagnosis. While it is a benign process, malignant transformation can occur and pathologists should be aware of this possibility. For this reason, additional sections may be recommended to rule out occult malignancy.

Acute Emphysematous Cholecystitis Rarely Accompanied by Necrotized Cystic Duct: A Case Report

Emphysematous cholecystitis is an acute abdominal disease characterized by gas in the gallbladder lumen and wall. Emphysematous cholecystitis and related cystic duct necrosis are rare, but if not noticed, they can cause a mortal picture up to perforation and sepsis. In this article, we present a case of emphysematous cholecystitis involving gangrenous gallbladder and necrotizing cystic duct, which developed suddenly in an immunosuppressive patient who presented to the emergency department with abdominal pain and was treated with rapid emergency successful surgery.

Necrotizing Fasciitis Secondary to Emphysematous Cholecystitis and Cholecystocutaneous Fistula: A Rare Case Report Presentation

Emphysematous cholecystitis is a rare subtype of acute cholecystitis characterized by the presence of gas in the gallbladder wall secondary to ischemia. Typically, this is a result of cystic artery vascular compromise with a concomitant infection from gas-forming organisms such as Clostridium species, Klebsiella species, or Escherichia coli. The mortality rate of acute emphysematous cholecystitis is 15% - 20% compared with 1.4% in uncomplicated acute cholecystitis. The subsequent development of a cholecystocutaneous fistula, an abnormal connection between the gallbladder and the skin, is also a rare complication of gallbladder disease. We describe a case of a 77-year-old male who presented with right flank necrotizing fasciitis which developed from a cholecystocutaneous fistula secondary to emphysematous cholecystitis. Once the necrotic tissues were adequately debrided, the large open wound was treated with negative pressure wound therapy with instillation (NPWT-i) utilizing hypochlorous acid (HOCL). The wound was closed with a split-thickness skin graft.

S372 Cystic Artery Pseudoaneurysm: A Rare Case of Upper Gastrointestinal Bleeding

Introduction: Cystic artery pseudoaneurysm (CAP) is a rare complication of acute cholecystitis and cholecystectomy. We present an unusual case of upper GI bleed due to CAP. Case Description/Methods: An elderly female presented with one month history of lethargy and unintentional weight loss. Clinical exam was unremarkable apart from pallor. Blood tests revealed severe iron deficiency anaemia and bland cholestasis. CT scan showed a common bile duct (CBD) mass and a gallbladder (GB) neck lesion with prominent regional lymph nodes, which was worrying for biliary malignancy. MRI scan showed a 3cm CBD stone with acute emphysematous cholecystitis and possible CAP at the GB neck. An urgent OGD and ERCP was done on the same day as she developed hematemesis and cholangitis. On endoscopy, there was active bleeding from possible enteric fistula at first part of duodenum (D1), this was treated with metal clips. During ERCP, haemobilia was noted on CBD cannulation. On cholangiogram, the endoclips were adjacent to distal CBD stone. A plastic stent was inserted into the CBD and she was referred to the surgeons. Cholecystectomy and CBD exploration was performed for definitive treatment. Intra-operatively, there was active bleeding into the GB from CAP. D1 was thinned out with adhesions to the GB. There was stale blood in the bile duct but no biliary-enteric fistula seen. CAP was sutured, adhesiolysis, subtotal cholecystectomy, omental patch repair of D1 and CBD stone was retrieved. Repeat OGD and ERCP with CBD stent removal done 2 months later showed healed D1 mucosa. Discussion: The clinical features of CAP include right upper quadrant pain, upper GI bleed due to haemobilia and abnormal liver enzymes. It is diagnosed on arterial phase of CT scan, angiography, MRI or during surgery. It is treated with surgery or angioembolization. This is a challenging case with delayed diagnosis of CAP as she lacks the typical presentation of CAP. A plain contrasted CT without arterial phase was done initially, which have mistaken the CAP as soft tissue lesion in GB. Endoscopic findings raises possibility of choledocho-duodenal fistula; this was excluded during surgery. The final diagnosis is acute calculous cholecystitis complicated by CAP with direct pressure on D1 leading to upper GI bleed. To our knowledge, this is the first case of CAP with such entity. In conclusion, CAP should be considered in patients with symptomatic gallstone disease and upper GI bleed in order to select appropriate imaging modality and guide therapy. Watch the video at https://tinyurl.com/ACGAbstractS372

Acute emphysematous cholecystitis due to clostridium perfringens: a rare entity requiring aggressive and early treatment.

Acute emphysematous cholecystitis is a rare entity (1% of acute cholecystitis) characterized by the presence of gas in the gallbladder lumen, gallbladder wall or even in the bile duct (pneumobilia). It is associated with arteriosclerosis, embolic events, and diabetes mellitus and as in other similar pathologies such as emphysematous gastritis or emphysematous pancreatitis the most frequently isolated microorganisms are Streptococcus pyogenes, Escherichia coli and Staphylococcus aureus, although others such as Proteus vulgaris, Pseudomonas aeruginosa, Clostridium perfringens and Klebsiella pneumoniae have also been found.

IS AN ACUTE CHOLECYSTITIS A LOCAL INFECTION? ANTIBIOTIC THERAPY PROBLEMS

Summary. Objective: to improve the results of surgical treatment of destructive forms of acute cholecystitis, taking into account the sensitivity of the isolated microflora to antibiotics.
 Materials and methods. 347 patients with acute cholecystitis (AC) have been operated in the surgical department of Kiev Regional Clinical Hospital in 2016 – 2019. The control group included 275 AC patients operated on in 2013–2015, similar in sex, age, comorbidities, treatment and surgical tactics to each other, but with an empirical choice of antibiotic therapy. Bacteriological studies were performed to 237 patients with destructive forms of acute cholecystitis, where 531 microflora isolates were seeded.
 Results and discussion. The AC treatment group patients (n=347) were arranged according to Tokyo guidelines (2013) into 3 grades. Mild course (grade I, n=38, 11 %), microbiological studies were not conducted. Antibiotic prophylaxis with beta-lactam antibiotics was used. At moderately severe AC (grade II, n = 260, 75 %) escalation antibiotic therapy was carried out. At severe disease (grade III, n = 49, 14 %) de-escalation antibiotic therapy was performed.
 Most often intestinal group microflora was sown. The highest sensitivity of microflora was marked for linezolid - 100 %. Also high sensitivity of microflora was revealed to beta-lactam antibiotics - 83.3 % (penicillins, cephalosporins, monobactams, and carbapenems).
 The highest resistance was marked for unprotected penicillins: penicillin — 67.7 %, ampicillin — 83.3 %, amoxicillin — 100 %, oxacillin — 100 %; among cephalosporins: cefixime — 75.0 %, cefuroxime — 66.7 %; among fluoroquinolones: lomefloxacin and pefloxa-cin — 100 % resistance to seeded aerobic microflora.
 In the control group (n=275) purulent complications were noted in 9.8 % (27 patients), fatal cases — 6, the total mortality rate was 2.18 %, postoperative — 1.45 % (4 patients). In the study group (n = 347), the number of purulent complications was reduced to 4 % (p˂0.01), the total mortality rate was reduced to 0.58 % (p˂0.05).
 Conclusions: 1. Acute obstructive cholecystitis, acute emphysematous (gas) cholecystitis and AC complicated by choledocholithiasis or cholangitis are referred to the local abdominal infectious process. 2. Infection is not a leading factor on first stage for emphysematous, vascular and post-traumatic forms of AC, but it develops in a destructive gall bladder on second stage. 3. For the patients of the first grade by Tokio guideline 2013 we recommend the use of antibiotic prophylaxis. Under moderate grade — escalation antibiotic therapy and under severe grade of the AC — de-escalation antibiotic therapy, followed by the use of selective antibacterial agents should be administered. 4. The highest selective sensitivity of seeded microflora in patients with destructive forms of AC was marked for oxazolidinones (linezolid) — (100 %), as well as for beta-lactam antibiotics (83.3 %). 5. The control group patients had decreased number of suppurations (from 9.8 to 4 %; p<0.01), and decreased mortality rate (from 2.18 to 0.58 %; p<0.05).

AB161. 182. Emphysematous cholecystitis: case report on a rare, life threatening presentation

: A 78-year-old gentleman with type 2 diabetes mellitus, atrial fibrillation, chronic kidney disease and hypertension presented to the emergency department with sudden onset of severe right upper quadrant with associated vomiting. White cell count showed a leukocytosis of 24×10×9/L and a C-reactive protein of 57 mg/L. An ultrasound abdomen revealed no acute gallbladder or biliary pathology. Computed tomography of the abdomen revealed pericholecystic fat stranding, an air-liquid level within the gallbladder and gas dissecting along a significant portion of the gallbladder wall—findings consistent with emphysematous cholecystitis, grade 3 with associated perforation and small volume of portal venous gas. Our patient underwent an emergency laparotomy with cholecystectomy. Pathology examination revealed acute acalculous gangrenous cholecystitis. Our patient required a 5-day admission to intensive care unit post-operatively. Emphysematous cholecystitis was first described at autopsy in 1901 by Stolz, who characterized emphysematous cholecystitis by the presence of air within the gallbladder and/or the biliary tree in the absence of an abnormal communication between the biliary system and the gastrointestinal tract. Emphysematous cholecystitis is a potentially life-threatening anaerobic infection, is a variant of acute cholecystitis. The mortality rate for acute emphysematous cholecystitis however is 15–50%. Despite the high mortality associated with gangrene and gallbladder perforation, patients with emphysematous cholecystitis do not exhibit alarming clinical signs of sepsis, and the presenting symptoms are often nonspecific and initially indistinguishable from those of uncomplicated acute cholecystitis. Patients with diabetic neuropathy may not experience typical right upper quadrant pain and maybe present with a paucity of symptoms.

Intra-abdominal Infection

The basic principles of rapid diagnosis, timely physiologic support, and definitive intervention for intra-abdominal infections have remained unchanged over the past century; however, specific management of these conditions has been transformed as a result of numerous advances in technology. This review covers clinical evaluation, investigative studies, options for intervention, early source control and duration of antimicrobial therapy, infections of the upper abdomen, infections of the lower abdomen, other abdominal infections, and special cases. Figures show an algorithm outlining the approach to a suspected upper abdominal infection, abnormal abdominal ultrasounds showing calculi in the gallbladder and confirming the diagnosis of acute acalculous cholecystitis, endoscopic retrograde cholangiopancreatographies showing a distal common bile duct stone in acute pancreatitis, extrinsic compression of the common hepatic duct by a stone in the Hartmann pouch, and endoscopic sphincterotomy for acute biliary decompression in acute obstructive cholangitis, air outlining the gallbladder and bile ducts in emphysematous cholecystitis, abdominal and pelvic CT scans showing pancreatic findings graded by Ranson into five categories, a splenic abscess, an inflamed and thickened appendix with surrounding fat stranding, appendiceal perforation and abscess formation, diverticulitis with a small amount of extraluminal air, left lower quadrant fluid collection consistent with peridiverticular abscess, diffuse inflammation and right upper quadrant extraluminal air, and thickening of the colonic wall with both intramural and extramural air, an algorithm outlining the approach to the patient with a suspected lower abdominal infection, upright chest x-ray and abdominal CT scans of patients with sudden-onset diffuse abdominal pain, and an omental (Graham) patch. Tables list diagnostic indicators of upper abdominal pain and fever, comparison of acute cholecystitis and emphysematous cholecystitis, Hinchey system for classification of perforated diverticulitis, Centers for Disease Control and Prevention (CDC) guidelines for diagnosis of pelvic inflammatory disease, and CDC guidelines for antibiotic treatment of pelvic inflammatory disease. This review contains 16 highly rendered figures, 5 tables, and 238 references

Intra-abdominal Infection

The basic principles of rapid diagnosis, timely physiologic support, and definitive intervention for intra-abdominal infections have remained unchanged over the past century; however, specific management of these conditions has been transformed as a result of numerous advances in technology. This review covers clinical evaluation, investigative studies, options for intervention, early source control and duration of antimicrobial therapy, infections of the upper abdomen, infections of the lower abdomen, other abdominal infections, and special cases. Figures show an algorithm outlining the approach to a suspected upper abdominal infection, abnormal abdominal ultrasounds showing calculi in the gallbladder and confirming the diagnosis of acute acalculous cholecystitis, endoscopic retrograde cholangiopancreatographies showing a distal common bile duct stone in acute pancreatitis, extrinsic compression of the common hepatic duct by a stone in the Hartmann pouch, and endoscopic sphincterotomy for acute biliary decompression in acute obstructive cholangitis, air outlining the gallbladder and bile ducts in emphysematous cholecystitis, abdominal and pelvic CT scans showing pancreatic findings graded by Ranson into five categories, a splenic abscess, an inflamed and thickened appendix with surrounding fat stranding, appendiceal perforation and abscess formation, diverticulitis with a small amount of extraluminal air, left lower quadrant fluid collection consistent with peridiverticular abscess, diffuse inflammation and right upper quadrant extraluminal air, and thickening of the colonic wall with both intramural and extramural air, an algorithm outlining the approach to the patient with a suspected lower abdominal infection, upright chest x-ray and abdominal CT scans of patients with sudden-onset diffuse abdominal pain, and an omental (Graham) patch. Tables list diagnostic indicators of upper abdominal pain and fever, comparison of acute cholecystitis and emphysematous cholecystitis, Hinchey system for classification of perforated diverticulitis, Centers for Disease Control and Prevention (CDC) guidelines for diagnosis of pelvic inflammatory disease, and CDC guidelines for antibiotic treatment of pelvic inflammatory disease. This review contains 16 highly rendered figures, 5 tables, and 238 references

Extensive involvement of liver parenchyma in emphysematous cholecystitis

Emphysematous cholecystitis is an uncommon variant of acute cholecystitis caused by gas producing organisms. Only 18-20 cases have been reported in English literature until January 2013. Herein, we present images of computed tomographic scans of a 60-year-old female suffering from abdominal pain and was diagnosed as having acute emphysematous cholecystitis with extensive liver parenchymal involvement. The extensive liver involvement our patient with emphysematous cholecystitis urged us to report this case.

腹腔内遊離ガスを伴った急性気腫性胆嚢炎の1例

腹腔内遊離ガスを伴った急性気腫性胆嚢炎の1例

胆石を伴う急性気腫性胆嚢炎症例 ―溶解剤, 低出力超音波, マイクロ波併用による非胆道鏡下治療―

胆石を伴う急性気腫性胆嚢炎症例 ―溶解剤, 低出力超音波, マイクロ波併用による非胆道鏡下治療―

Acute Emphysematous Cholecystitis

Received: August 27, 2009 Accepted for publication: September 18, 2009 From the Department of Emergency Medicine, Department of Medical Imaging Division of Hepatogastroenterology, Department of Internal Medicine, Far Eastern Memorial Hospital, Taipei, Taiwan Address reprint requests and correspondence: Dr. Min-Po Ho Department of Emergency Medicine, Far Eastern Memorial Hospital 21 Section 2, Nanya South Road, Panchiao 220, Taipei County, Taiwan (R.O.C.) Tel: (02)89667000 ext 1122 Fax: (02)89660454 E-mail: hominpo@yahoo.com.tw 急重症影像

Acute emphysematous cholecystitis with initial normal radiological evaluation: a fatal diagnostic pitfall in the ED

Abstract Acute emphysematous cholecystitis is a relatively rare disease, a severe variant of acute cholecystitis, that predominantly affects elderly diabetic men. The apparently high mortality and morbidity associated with acute emphysematous cholecystitis have previously emphasized the importance of prompt diagnosis and emergent surgical intervention. Radiological evaluation including plain plain abdominal radiograph (KUB), abdominal sonography, and computed tomography of abdomen is the cornerstone of diagnosis of acute emphysematous cholecystitis. We describe a nondiabetic woman who developed sepsis due to acute emphysematous cholecystitis with rapid deterioration within 24 hours. She was misdiagnosed as having peptic ulcer disease initially due to normal KUB, abdominal sonography, and computed tomography of abdomen.

Emphysematous Cholecystitis in a Patient with Gastrointestinal Stromal Tumor Treated with Sunitinib

A 50-year-old man had a metastatic gastrointestinal stromal tumor that was refractory to imatinib. He was prescribed a 6-week course of treatment with oral sunitinib 50 mg/day. During the fourth week of his first cycle of treatment with the drug, the patient developed acute-onset, right upper quadrant pain associated with nausea, vomiting, and fever; laboratory tests revealed leukocytosis and mild hyperbilirubinemia. He was diagnosed with acute emphysematous cholecystitis, which was treated with broad-spectrum antibiotics and percutaneous cholecystostomy. His symptoms resolved, and he successfully completed his course of therapy with sunitinib. Using the Naranjo adverse drug reaction probability scale, a score of 5 was derived, which indicates that the likelihood was probable that this adverse event was caused by sunitinib.

Acute emphysematous cholecystitis.

Abstract Three cases of acute emphysematous cholecystitis are described and the literature reviewed. After considering clinical and radiological features, it is suggested that occlusion of the cystic artery may be the cause of this condition.

Metastatic Melanoma of the Gallbladder Presenting as Acute Emphysematous Cholecystitis

Metastatic Melanoma of the Gallbladder Presenting as Acute Emphysematous Cholecystitis

A Successfully Treated Case of Severe Perforated Acute Emphysematous Cholecystitis

A Successfully Treated Case of Severe Perforated Acute Emphysematous Cholecystitis

La cholécystite emphysémateuse : une entité pathologique. À propos d’un cas

Emphysematous cholecystitis is a rare but real entity, which have to be recognized early in order to quickly start the best treatment. We report a case of acute emphysematous cholecystitis diagnosed with computed tomography. A successful outcome was obtained by antibiotherapy and cholecystectomy in emergency.

急性気腫性胆嚢炎の6例

急性気腫性胆嚢炎の6例