Emphysematous cholecystitis is a rare form of acute cholecystitis where gallbladder wall necrosis causes gas formation in the lumen or wall. It is a surgical emergency, due to the high mortality from gallbladder gangrene and perforation.
Men are affected twice as commonly as women (reverse is true in most cases of acute cholecystitis).
The majority of patients are between 50 and 70 years of age and have underlying diabetes mellitus.
Clinical manifestation is often insidious and may then progress rapidly. Up to one-third of patients may be afebrile and localised tenderness is often not a dominant clinical feature.
Vascular compromise of the cystic artery is thought to play a significant role in causing emphysematous cholecystitis. It is associated with acalculous cholecystitis (present in ~50% of cases 9-11) and carries a higher incidence of gallbladder perforation. Commonly isolated organisms include Clostridium welchii / perfringens, Escherichia coli and Bacteroides fragilis 1,12.
On imaging, the condition is diagnosed when there is radiographic demonstration of air in the gallbladder wall +/- biliary ducts, in the absence of an abnormal communication with the gastrointestinal tract 2.
Ultrasonography may demonstrate highly echogenic reflectors with low-level posterior shadowing and reverberation artifact ("dirty" shadowing and "ring-down" artifact) 7.
A less common but more specific finding is small, non-shadowing echogenic foci rising up from the dependent portions of the gallbladder lumen, similar to effervescing bubbles in a glass of champagne (champagne sign).
CT is considered the most sensitive and specific imaging modality for identifying gas within the gallbladder lumen or wall 4. The presence of a pneumoperitoneum indicates perforation.
Because there is usually cystic duct obstruction, gas is present in the bile ducts in only 20% of cases15-17
Hepatobiliary nuclear imaging may demonstrate non-visualisation of the gallbladder, along with a region of increased hepatic activity adjacent to the gallbladder fossa. This feature is sometimes termed the rim sign 10.
Treatment and prognosis
Treatment is emergent surgical intervention. Overall mortality rate is ~20% (range 15-25%), compared with <5% in uncomplicated cases of acute cholecystitis. Percutaneous cholecystostomy tube placement may be an option for patients who are too unwell for surgery 13.
History and etymology
It was initially described by C F Hegner in 1931 5.
- if in doubt of the diagnosis on ultrasound, obtain a CT to confirm the diagnosis
- 1. Grayson DE, Abbott RM, Levy AD et-al. Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics. 22 (3): 543-61. Radiographics (full text) - Pubmed citation
- 2. Sunnapwar A, Raut AA, Nagar AM et-al. Emphysematous cholecystitis: Imaging findings in nine patients. Indian J Radiol Imaging. 2011;21 (2): 142-6. doi:10.4103/0971-3026.82300 - Free text at pubmed - Pubmed citation
- 3. Jolly BT, Love JN. Emphysematous cholecystitis in an elderly woman: case report and review of the literature. J Emerg Med. 11 (5): 593-7. - Pubmed citation
- 4. Grand D, Horton KM, Fishman EK et-al. CT of the gallbladder: spectrum of disease. AJR Am J Roentgenol. 2004;183 (1): 163-70. AJR Am J Roentgenol (citation) - Pubmed citation
- 5. Hegner CF. Gaseous pericholecystitis with cholecystitis and cholelithiasis. Arch Surg 1931; 22:993-1000.
- 6. Brandon JC, Glick SN, Teplick SK et-al. Emphysematous cholecystitis: pitfalls in its plain film diagnosis. Gastrointest Radiol. 1988;13 (1): 33-6. doi:10.1007/BF01889020 - Pubmed citation
- 7. Parulekar SG. Sonographic findings in acute emphysematous cholecystitis. Radiology. 1982;145 (1): 117-9. Radiology (citation) - Pubmed citation
- 8. Mcmillin K. Computed tomography of emphysematous cholecystitis. J Comput Assist Tomogr. 9 (2): 330-2. - Pubmed citation
- 9. Bortoff GA, Chen MY, Ott DJ et-al. Gallbladder stones: imaging and intervention. Radiographics. 20 (3): 751-66. Radiographics (citation) - Pubmed citation
- 10. Meekin GK, Ziessman HA, Klappenbach RS. Prognostic value and pathophysiologic significance of the rim sign in cholescintigraphy. J. Nucl. Med. 1987;28 (11): 1679-82. J. Nucl. Med. (link) - Pubmed citation
- 11. O'connor OJ, Maher MM. Imaging of cholecystitis. AJR Am J Roentgenol. 2011;196 (4): W367-74. doi:10.2214/AJR.10.4340 - Pubmed citation
- 12. Garcia-sancho tellez L, Rodriguez-montes JA, Fernandez de lis S et-al. Acute emphysematous cholecystitis. Report of twenty cases. Hepatogastroenterology. 46 (28): 2144-8. - Pubmed citation
- 13. Smith EA, Dillman JR, Elsayes KM et-al. Cross-sectional imaging of acute and chronic gallbladder inflammatory disease. AJR Am J Roentgenol. 2009;192 (1): 188-96. doi:10.2214/AJR.07.3803 - Pubmed citation
- 14. Konno K, Ishida H, Naganuma H et-al. Emphysematous cholecystitis: sonographic findings. Abdom Imaging. 2002;27 (2): 191-5. Pubmed citation
- 15. Chapman and Nakielny's Aids to Radiological Differential Diagnosis 6th Edition (2014)
- 16. Shah PA, Cunningham SC, Morgan TA, Daly BD. Hepatic Gas: Widening Spectrum of Causes Detected at CT and US in the Interventional Era.Radiographics (2011); 31: 1403-1413
- 17. Harley WD, Kirkpatrick RH, Ferucci JT. Gas in the bile ducts (pneumobilia) in emphysematous cholecystitis. American Journal of Roentgenology (1978);131: 661-663
Ultrasound - gallbladder
- ultrasound (introduction)
- gallbladder ultrasound
- diffuse gallbladder wall thickening (differential)
- focal gallbladder wall thickening (differential)
- gallbladder sludge
- acute cholecystitis
- chronic cholecystitis
- gallbladder polyp
- porcelain gallbladder
- gallbladder carcinoma
- gallbladder metastases
- gallbladder lymphoma
- gallbladder volvulus / torsion
- variants and anomalies