Gangrenous cholecystitis

Changed by Andrew Murphy, 7 Feb 2023
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Disclosures - updated 4 Sep 2022: Nothing to disclose

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Gangrenous cholecystitis is the most common complication of acute cholecystitis, affecting ~15% (range 2-30%) of patients. 

Epidemiology

Risk factors

Pathology

Gangrenous cholecystitis occurs as a result of ischaemia with necrosis of the gallbladder wall 4. Cystic duct obstruction results in increased gallbladder luminal pressure, which may lead to gallbladder wall ischaemia progressing to necrosis. Gallbladder perforation occurs in about 10% of necrotic gallbladders.

Radiographic features

Ultrasound

In addition to features of acute cholecystitis, the following may help diagnose gangrenous cholecystitis 3:

  • intraluminal membranes suggesting sloughing of the necrotic mucosa

  • asymmetrical wall thickness

    • with possible wall disruption and/or ulceration

  • focal perfusion defects on Doppler (representing areas of necrosis)

  • variable absence of the sonographic Murphy sign 7

    • A negative sonographic Murphy Sign occurs in about a third of gangrenous cholecystitis. This may be attributed to ischaemic denervation of the gallbladder 6

CT

In addition to features of acute cholecystitis, the following may help diagnose gangrenous cholecystitis 1:

Treatment and prognosis

Mortality is increased compared to uncomplicated acute cholecystitis, estimated at between 15-50% 4. 

  • -<li><p>male</p></li>
  • -<li><p>increasing age</p></li>
  • -<li><p>delayed surgery</p></li>
  • -<li><p>cardiovascular disease</p></li>
  • -<li><p><a href="/articles/diabetes-mellitus">diabetes mellitus</a></p></li>
  • -<li><p><a href="/articles/systemic-inflammatory-response-syndrome">systemic inflammatory response syndrome</a><sup> 5</sup></p></li>
  • -</ul><h4>Pathology</h4><p>Gangrenous cholecystitis occurs as a result of ischaemia with necrosis of the gallbladder wall <sup>4</sup>. Cystic duct obstruction results in increased gallbladder luminal pressure, which may lead to gallbladder wall ischaemia progressing to necrosis. Gallbladder perforation occurs in about 10% of necrotic gallbladders.</p><h4>Radiographic features</h4><h5>Ultrasound</h5><p>In addition to features of acute cholecystitis, the following may help diagnose gangrenous cholecystitis <sup>3</sup>:</p><ul>
  • -<li><p>intraluminal membranes suggesting sloughing of the necrotic mucosa</p></li>
  • +<li>male</li>
  • +<li>increasing age</li>
  • +<li>delayed surgery</li>
  • +<li>cardiovascular disease</li>
  • +<li><a href="/articles/diabetes-mellitus">diabetes mellitus</a></li>
  • -<p>asymmetrical wall thickness</p>
  • -<ul><li><p>with possible wall disruption and/or ulceration</p></li></ul>
  • +<a href="/articles/systemic-inflammatory-response-syndrome">systemic inflammatory response syndrome</a><sup> 5</sup>
  • -<li><p>focal perfusion defects on Doppler (representing areas of necrosis)</p></li>
  • -<li>
  • -<p>variable absence of the <a href="/articles/sonographic-murphy-sign-1">sonographic Murphy sign</a> <sup>7</sup></p>
  • -<ul><li><p>A negative sonographic Murphy Sign occurs in about a third of gangrenous cholecystitis. This may be attributed to ischaemic denervation of the gallbladder <sup>6</sup></p></li></ul>
  • +</ul><h4>Pathology</h4><p>Gangrenous cholecystitis occurs as a result of ischaemia with necrosis of the gallbladder wall <sup>4</sup>. </p><h4>Radiographic features</h4><h5>Ultrasound</h5><p>In addition to features of acute cholecystitis, the following may help diagnose gangrenous cholecystitis <sup>3</sup>:</p><ul>
  • +<li>intraluminal membranes</li>
  • +<li>asymmetrical wall thickness<ul><li>with possible wall disruption and/or ulceration</li></ul>
  • +</li>
  • +<li>focal perfusion defects on Doppler (representing areas of necrosis)</li>
  • +<li>variable absence of the <a href="/articles/sonographic-murphy-sign-1">sonographic Murphy sign</a> <sup>7</sup><ul><li>attributed to ischaemic denervation of the gallbladder <sup>6</sup>
  • +</li></ul>
  • -<li><p>gallbladder wall air or lumen <a href="/articles/emphysematous-cholecystitis">gas</a> (<a href="/articles/emphysematous-cholecystitis" title="Emphysematous cholecystitis">emphysematous cholecystitis</a>)</p></li>
  • -<li><p>focal irregularity or defect in the gallbladder wall</p></li>
  • -<li><p>intraluminal membranes</p></li>
  • -<li><p>absence of mural enhancement</p></li>
  • -<li><p><a href="/articles/pericholecystic-abscess">pericholecystic abscess</a></p></li>
  • +<li>gallbladder wall or lumen <a href="/articles/emphysematous-cholecystitis">gas</a> (<a title="Emphysematous cholecystitis" href="/articles/emphysematous-cholecystitis">emphysematous cholecystitis</a>)</li>
  • +<li>focal irregularity or defect in the gallbladder wall</li>
  • +<li>intraluminal membranes</li>
  • +<li>absence of mural enhancement</li>
  • +<li><a href="/articles/pericholecystic-abscess">pericholecystic abscess</a></li>

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