An 85-year-old man
presents to the emergency room with right upper abdominal
pain and weakness for the past 2 days. He denies having
shortness of breath, fevers, or chest pain. He has a
medical history significant for hypertension, congestive
heart failure, and adult-onset diabetes. He states that he
is taking all of his medications as prescribed.
On physical examination, the patient has a blood pressure
of 157/51 mm Hg, heart rate of 112 beats per minute,
temperature of 36.4°C (97.5°F), and respiratory rate of
20 breaths per minute. The patient is visibly jaundiced on
general inspection. Findings on cardiac and respiratory
examination are normal, but he has tenderness to palpation
in the right upper quadrant, with guarding. No abdominal
rigidity or rebound is noted.
Laboratory investigations reveal the following levels: WBC
count 15.3 X 109/L, total bilirubin 18.2 mg/dL,
direct bilirubin 14.2 mg/dL, alkaline phosphatase 132 U/L,
aspartate aminotransferase 152 U/L, alanine
aminotransferase 63 U/L, amylase 185 U/L, and lipase 81
U/L. Ultrasonography of the right upper quadrant reveals
abnormalities (see Image 1), and a follow-up abdominal CT
scan confirms the findings (see Image 2).
is the diagnosis?
emphysematous cholecystitis (AEC) and abscess in the
liver: The sonogram of the right upper quadrant (see
Image 1) demonstrates a curvilinear pattern of
poorly marginated, high-level echoes outlining the
gallbladder wall, a finding that suggests the
presence of air (arrows). The image also shows
high-level echoes in the liver parenchyma, another
finding suggestive of air (arrowhead). The follow-up
CT scan confirms these findings (see Image 2).
Multiple foci of air are seen in the wall of the
gallbladder (arrowheads), with inflammation of
surrounding fat consistent with AEC. In addition,
large focus of air is seen in the liver parenchyma
with an associated hypoattenuating area consistent
with an abscess (arrowhead).
AEC is a variant of acute cholecystitis
distinguished by air in the gallbladder wall. It
usually occurs in men older than 60 years who have
predisposing factors of atherosclerotic disease,
diabetes mellitus (20-50%), and other debilitating
diseases. Patients with long-standing diabetes and
an element of peripheral neuropathy may not complain
of the classic symptom of right upper quadrant pain
radiating to the back. Unlike other organs, the
gallbladder lacks collateral blood flow, and it
receives all of its vascular supply from the
solitary cystic artery.
Calculous AEC with secondary inflammation and
occlusion of the cystic artery accounts for 70-80%
of observed cases. The rest of the cases result from
acalculous AEC and are due to compromised flow
through the cystic artery due to primary vascular
occlusion, watershed hypotension, or secondary
embolic disease. Regardless of the etiology, the
result is the proliferation of gas-forming organisms
in the lumen of the gallbladder with subsequent
development of mural crepitus. Usual pathogenic
isolates include Clostridium perfringes,
Escherichia coli, Bacteroides fragilis,
anaerobic staphylococci, and streptococci.
In the United States, AEC accounts for approximately
5000 cases, or 1% of all cases of acute
cholecystitis, each year. CT scanning is superior to
plain radiography and ultrasonography because of its
nearly 100% sensitivity for the detection of air and
its high specificity of the observed findings. AEC
increases the surgical mortality risk compared with
nonemphysematous cholecystitis. Mortality rates vary
from 15-25% and are mainly secondary to sepsis and
AA, Prospere R: Emphysematous cholecystitis.
eMedicine Journal [serial online]. Accessed June
27, 2005. Available at: http://www.emedicine.com/med/topic655.htm.
S, Demir K, Beser M: Case 1150. Acute
emphysematous cholecystitis. European
Association of Radiology Journal [serial
online]. Accessed June 27, 2001. Available at: http://www.eurorad.org/case.php?id=1150.
RA, Costello P, Duszlak E: Computed tomography
in acute cholecystitis: new observations. Am J
Roentgenol AJR 1983 Oct;141(4):697-701.
to further Information on:
more information on AEC, see the eMedicine article Emphysematous
Cholecystitis (within the Internal Medicine specialty).