Acute emphysematous cholecystitis. Report of a case and review of the literature

The authors report a case of acute emphysematous cholecystitis (AEC) operated on at the University Hospital of ABC Medical School (S?o Paulo), with a review of the literature. The infrequency of this finding and the participation of local ischemic factors, associated with secondary infection by gas forming bacteria are pointed out. The authors emphasize the importance of considering this entity potentially more severe than acute non-emphysematous cholecystitis (AnEC) because in AEC gallbladder gangrene is 30 times higher and perforation occurs 5 times more frequently than in AnEC. Besides, the patient with AEC may shows no clinical signs of severity, as in the case reported, where gallbladder gangrene was seen at surgery. In AEC, diagnosis is established usually when the plain abdominal X-ray shows gas within the gallbladder or in its walls. The best results are obtained with cholecystectomy and antibiotic therapy.     

Diagnosis of emphysematous cholecystitis by computerized tomography.

A case of emphysematous cholecystitis is presented in which computerized tomography helped to confirm the diagnosis and the extent of disease preoperatively. This unusual disorder is briefly reviewed and the clinical and radiographic findings are discussed.     

Percutaneous drainage of emphysematous cholecystitis associated with pneumoperitoneum.

Emphysematous cholecystitis, a relatively rare variant of acute cholecystitis, is associated with high morbidity and mortality rates. In the presence of a concomitant pneumoperitoneum, these rates may be considered even higher, approaching those of perforation of the gallbladder. The first choice of treatment in cases presenting with pneumoperitoneum is emergency laparotomy. We performed a staged procedure as a second best alternative. In a 65 year-old female patient, initial percutaneous cholecystostomy with a strict intravenous antibiotics regimen, and subsequent cholecystectomy 6 months, later was carried out with successful outcome. A review of the literature revealed 13 other cases of this combination. Treatment modalities and outcome of these patients are discussed.     

Percutaneous gallbladder drainage in emphysematous cholecystitis

Emphysematous cholecystitis is a serious disorder with a high mortality and morbidity. We report successful drainage of the gallbadder in a male diabetic patient with emphysematous cholecystitis in whom surgery was considered contraindicated because of his poor cardiac status.     

Hyperbaric oxygenation as adjuvant therapy to surgery of emphysematous cholecystitis.

Three cases of emphysematous cholecystitis are presented. The role of hyperbaric oxygenation as excellent adjuvant therapy to urgent surgical as well as intensive conservative treatment is emphasized.     

Gallbladder torsion-induced emphysematous cholecystitis in a 16-year-old boy

The patient was a 16-year-old boy who had turned to the right rapidly as he fielded a baseball that had come to him quickly. Two days after this event, which occurred in July 2004, he was admitted to hospital with repeated vomiting and increasing right hypochondralgia. Laboratory examination on admission showed elevation of the white blood count and of serum C-reactive protein and total bilirubin. Computed tomography on admission demonstrated an enlarged gallbladder and a thickened wall without gallstones, and magnetic resonance imaging performed 1 day later showed air within the gallbladder wall. His symptoms worsened, with a positive Murphy's sign, and emergency laparotomy was performed, with a diagnosis of emphysematous cholecystitis. Intraoperatively, the gallbladder was dark red, necrotic, distended, and enlarged. The cystic duct was attached only to the mesentery, and the gallbladder was floating freely, with the neck of the gallbladder having rotated 180° counterclockwise, leading to a definitive diagnosis of gallbladder torsion with emphysematous cholecystitis. Cholecystectomy was performed, and analysis of bile showedEscherichia coli to be the causative organism. Histopathologic examination revealed necrotized cholecystitis. The patient is doing well 25 months after surgery, with an uneventful postoperative course.     

Pneumomediastinum as a complication of emphysematous cholecystitis: Case report

Background  

Emphysematous cholecystitis is a variant of acute cholecystitis which is generally caused by gas-forming organisms. Emphysematous cholecystitis may cause gas spreading within the subcutaneous tissue, peritoneal cavity and retroperitoneum.     

Perforated emphysematous cholecystitis managed by endoscopic transpapillary gallbladder drainage

An 88-year-old woman with dementia was diagnosed as having perforated emphysematous cholecystitis with localized peritonitis. Because she was at high risk for surgery, gallbladder drainage was required before surgery. Endoscopic transpapillary gallbladder drainage instead of percutaneous transhepatic biliary drainage was performed because bile could leak from the puncture site to free space around the perforated gallbladder. After the insertion of a nasobiliary drainage tube, the gallbladder was drained and cleaned with saline solution. Subsequently, a nasobiliary drainage tube was replaced with a double-pigtail stent because she was at high risk of dislodging the nasobiliary drainage tube. Although clinical improvement was observed, she was treated conservatively without surgery. She was followed up for 6 months without developing cholecystitis. For perforated cholecystitis without developing panperitonitis, endoscopic transpapillary gallbladder drainage would be an effective option as a bridge to surgery for the initial treatment and as an alternative to surgery for long-term management for a later treatment. This is the first reported case of perforated emphysematous cholecystitis with localized peritonitis treated with endoscopic transpapillary gallbladder drainage.     

Acute cholecystitis

Opinion statement Patients with a diagnosis of acute cholecystitis need to be hospitalized, with surgery (ie, cholecystectomy) being the treatment of choice. While hospitalized, they should be treated with intravenous hydration and with intravenous antibiotics covering enteric organisms. They should receive nothing by mouth and may require a nasogastric tube if ileus is present. The use of such conservative management for 24 to 48 hours allows the inflammatory and infectious processes to "cool down." Early surgery performed right after this initial period of conservative therapy is preferred over delayed surgical management (ie, discharge of the patient and readmission for the surgery 6 to 8 weeks later). Several studies have shown that early cholecystectomy not only has no adverse effects on complication rates but also leads to shorter hospital stays and quicker return to productivity [1,2]. Laparoscopic cholecystectomy is the preferred operation because it is associated with a shorter hospital stay, less pain, and earlier return to productivity than is open cholecystectomy. There is an increase in the frequency of bile duct injury with this procedure, however. In patients who are poor surgical candidates, cholecystostomy can be performed via percutaneous catheter drainage of the gallbladder with the patient under local anesthesia [3]. In addition, endoscopic transpapillary drainage with or without gallstone dissolution (methyl tert-butyl ether [MTBE]) has been demonstrated to be an effective alternative to surgery in high-risk patients with acute calculous cholecystitis [4].     

Acute acalculous cholecystitis. A review.

Acute acalculous cholecystitis is an uncommon but very serious illness, that, if undiagnosed, may lead to gallbladder perforation and death. The condition has numerous causes that result in bile stasis and ischemia leading to inflammation and infection in the gallbladder wall. The bedside diagnosis may be difficult, especially in critically ill patients. Current imaging techniques including ultrasonography, computer tomography, and radionuclide cholescintigraphy are very helpful. Depending on the clinical situation, the gallbladder should either be drained by a surgical or percutaneous cholecystostomy under local anesthesia or removed.     

Acute cholecystitis: radiological management.

Acute cholecystitis is a common condition which may be difficult to diagnose with confidence on clinical grounds alone. A large number of techniques are now available for imaging the gall bladder but, in practice, ultrasonography and cholescintigraphy are of greatest value. The former is cheap, readily available and features such as the presence of gall stones, gall bladder wall inflammation and a positive sonographic Murphy sign strongly suggest the diagnosis of acute cholecystitis. In addition to its diagnostic uses, ultrasonographically guided percutaneous cholecystostomy provides an alternative and sometimes life-saving form of treatment in those patients who are unfit for surgery. Cholescintigraphy is a highly accurate, non-invasive method for assessing patency of the cystic duct but is not always available in the emergency situation and takes longer to perform than an ultrasound examination. Acute cholecystitis, however, has many manifestations and may be calculous or acalculous, be associated with a patent or obstructed cystic duct, and may be complicated or uncomplicated. Imagining modalities other than those mentioned above may be useful in certain circumstances and this chapter aims to present the advantages and disadvantages of each technique in order to provide guidance for the clinician caring for a patient with suspected acute cholecystitis.     

Acute acalculous cholecystitis in leptospirosis.

The authors present three patients with acalculous cholecystitis seen at a tertiary care center in Bangkok. The first patient was explored surgically because peritonitis was suspected. The two other patients were treated conservatively with antibiotics and supportive care, and they recovered fully. The diagnosis of leptospirosis was confirmed by increasing antibody titers in three patients and by blood culture in one patient. Leptospira were not detected in the surgical specimen. Leptospirosis is a systemic disease that can present with a multitude of symptoms and signs including right upper quadrant pain mimicking cholecystitis. A high level of awareness and appropriate laboratory studies should allow early diagnosis and may prevent unnecessary surgical intervention.     

Acute cholecystitis and Fasciola sp. infection in Thailand: report of two cases

Two cases of fascioliasis gigantica from Northeast Thailand presenting with cholecystitis and gall stones were reported. Both cases complained of abdominal pain. On laparotomy the worms were found. In one case five worms were recovered during bile duct exploration and bile drainage; eggs were also revealed in the bile. In the other case of ectopic fascioliasis one young adult worm was found in a nodule which adhered to liver and diaphragm. The parasites were identified as Fasciola gigantica.