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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

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
For more information, click on the link if you see this icon

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.