Emphysematous Cholecystitis
Perforation of the Gallbladder

• General considerations
  • Acute infection of gallbladder caused by gas-forming organism
  • In about 1/3 = clostridium perfringens
  • Also E. Coli and Klebsiella
  • Rare – only 1% of all cases of acute cholecystitis
  • Occurs more often in men
  • As opposed to gallbladder disease in general which occurs more often in women
  • Mostly are elderly patients (>60) with diabetes
  • Vascular compromise of the cystic artery may play a role in the etiology
  • Gallstones may be associated with the disease but are not thought to cause it
  • Gas may occur in the wall and/or the lumen
  • May spread to pericholecystic tissue
  • Rarely, gas may escape into the bile ducts
  • This is rare since cystic duct is usually occluded in cholecystitis
  • Clinical findings
  • As with cholecystitis, right upper quadrant (RUQ) pain and tenderness
  • Leukocytosis
  • Jaundice is rare
  • Imaging findings
  • Conventional radiography
  • May show air in the wall or lumen of the gallbladder
  • Air-fluid levels in the gallbladder will only be seen with images obtained with a horizontal beam, not on supine radiographs
  • Gas may spread to the pericholecystic tissues
  • These findings, if present on the conventional radiograph, usually herald a poor outcome from late-stage disease
  • US findings  
  • Indistinct shadowing emanating from wall or lumen of gallbladder
  • “Ring-down effect” or “comet tail” from shadowing from air in gallbladder lumen
  • CT findings of cholecystitis
  • Air in gallbladder wall is diagnostic of this disease
  • Most common signs of non-emphysematous cholecystitis are gallbladder wall thickening >3mm, and
  • Cholelithiasis
  • Increased density of bile (>20 H)
  • Loss of clear definition of gallbladder wall
  • Pericholecystic fluid such as a halo of edema
  • Treatment
  • Definitive care involves surgical intervention
  • Preoperative percutaneous drainage may improve survival
  • Emergency cholecystectomy
  • Mortality of 15-25%
  • Complications
  • Fivefold increase in perforation over uncomplicated acute cholecystitis
  • Perforation of the gallbladder
  • Frequency is declining because of earlier diagnosis of acute cholecystitis
  • Diagnosis
  • Pre-perforation conventional radiograph showing stones clustered in gallbladder may subsequently show stones scattered in RUQ after perforation
  • Pericholecystic fluid collection on CT or US (not-specific)
  • Scintography may show radiotracer outside of gallbladder in Morrison’s pouch or flank
  • Treatment
  • Preoperative percutaneous drainage of gallbladder and biloma
  • Emergency surgery

Emphysematous Cholecystitis. Supine view of the abdomen shows air in the wall (blue arrows) of the gallbladder (GB). There is also a lucency within the lumen of the gallbladder (GB) suggesting air inside the lumen. There is no air-fluid level visible because this radiograph is obtained supine with a vertical x-ray beam. Just superior to the gallbladder is another collection of air (red arrow) that represents a pericholecystic abscess. The yellow arrow points to the end of a PEG tube in the stomach.
For this same photo without the arrows, click here
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Gore, R. and Levine, M: textbook of Gastrointestinal; Radiology, W.B. Saunders, 2000.

Moss, A., Gamsu, G. and Genant, H.: Computed Tomography of the Body. W.B. Saunders,1992.