Emphysematous cholecystitis with gallbladder perforation

Case contributed by dr Nerses Nersesyan

Presentation

History of advanced Alzheimer's disease. Diffuse abdominal pain.

Patient Data

Age: 85 years
Gender: Male

Due to advanced Alzheimer's, the patient's positioning for the study was suboptimal. Round centro-abdominal epigastric hypodensity in plain abdominal radiography triggered the suspicion of gas within the gallbladder wall. 

Round centro-abdominal epigastric hypodensity is indicated by green arrows. 

Unenhanced CT demonstrates intramural and intraluminal gas collections in gallbladder. Focis of air near the medial gallbladder wall  and scattered through peritoneum. Patient was too sick for oral or intravenous contrast administration. 

CT findings are compatible with emphysematous cholecystitis with gallbladder perforation and pneumoperitoneum. 

Gas within the gallbladder indicated by star. Gas within gallbladder wall indicated by solid line. Free gas indicated by open and closed arrows. 

Case Discussion

Emphysematous cholecystitis is a severe complication of acute cholecystitis caused by a gas forming bacteria such as Clostridium perfringens, Escherichia coli, and Bacillus fragilis.

Gas may be present either within the lumen or the wall of the gallbladder. It is more common in patients with diabetes and carries a greater risk of perforation. Acute gallbladder perforation has a very high mortality due to generalized bile peritonitis.

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