Managing silent threats: Unveiling gangrenous complication in acute emphysematous cholecystitis.

Emphysematous cholecystitis is a potentially life-threatening variant of acute cholecystitis, characterized by the presence of gas in the gallbladder wall/lumen due to the proliferation of gas-producing bacteria. Symptoms include upper right quadrant pain, fever, nausea, and vomiting. Laboratory tests may show nonspecific indications of systemic infection, and radiological assessment, especially CT scanning, is crucial for diagnosis. This case underscores the significance of early diagnosis and intervention in managing emphysematous cholecystitis to prevent serious complications and reduce the higher mortality rate compared to acute cholecystitis.

Emphysematous Calculous Cholecystitis Diagnosed with Abdominal CT in a Diabetic Female Patient - Case Report.

Emphysematous cholecystitis is reported to have a low incidence of less than 1% in all cases of acute cholecystitis and yet a high mortality rate of up to 15%. It is most commonly seen in male diabetic patients with advanced age. The diagnosis is established with the presence of gas in the gallbladder lumen and/or within its wall which can be seen on plain abdominal radiography, abdominal ultrasound, and abdominal computerized tomography. The clinical presentation refers to one of acute cholecystitis, but the treatment requires prompt cholecystectomy since the patient's condition can deteriorate due to the possibility of gallbladder perforation. We present a case of a 71-year-old female diabetic patient with calculous emphysematous cholecystitis treated with emergency open cholecystectomy.

Survival in a Case of Emphysematous Cholecystitis With Sepsis Caused by Clostridium perfringens.

A 77-year-old man presented to the Department of Internal Medicine with a chief complaint of abdominal pain. During the outpatient examination, a computed tomography (CT) scan showed gallstones. The patient developed worsening abdominal pain and fever and was admitted to the emergency department. He was diagnosed with cholecystitis and hospitalized. Treatment with antimicrobial agents was initiated. On the second day of hospitalization, the patient developed a fever of 39°C, hypotension, and oliguria. An emergency CT scan was performed, which showed gas production in the gallbladder. He was diagnosed with emphysematous cholecystitis, and emergency percutaneous transhepatic gallbladder drainage was performed. The patient was transferred to the high-care unit, and intensive care was initiated. On the eighth day, a follow-up CT scan showed an abscess in the gallbladder bed, and drainage was performed percutaneously. His general condition gradually improved, and he was discharged from the hospital on day 24. The patient was readmitted for cholecystectomy three months after the initial admission. The prognosis of sepsis caused by Clostridium perfringens is extremely poor, with a mortality rate of 70%-100%. We present a case of emphysematous cholecystitis successfully treated with multimodal treatment despite the presence of sepsis due to Clostridium perfringens and discuss the possible prognostic factors by reviewing the literature.

Perforated Emphysematous Cholecystitis: A Race Against Time.

Emphysematous cholecystitis is a rare infection of the gallbladder that stems from acute cholecystitis. It can rapidly progress and perforate the gallbladder, which would require urgent surgical intervention. A perforated gallbladder can be diagnosed using an abdominal computed tomography by confirming the presence of air in the gallbladder lumen with adjacent extraluminal air. The causes of ruptured emphysematous cholecystitis include, but are not limited to, diabetes, atherosclerotic changes in blood vessels, and infection with Clostridium perfringens, Escherichia coli, and Klebsiella spp., and is usually present in diabetic men. We report on a 57-year-old female who developed gall bladder perforation with an overflow of gallstones into the peritoneum without a history of diabetes or atherosclerotic disease. Due to the vast availability of computerized tomography and early surgical intervention, the rate of mortality due to perforated emphysematous cholecystitis has decreased over the last few decades.

Air in gallbladder: Emphysematous cholecystitis or else?

Gas in gallstones represents a rare but well described radiological finding. Other causes of gas in gallbladder include biliary-enteric fistula, sphincterotomy, gas forming organisms cholangitis. However, gas in gallbladder raises suspicion of emphysematous cholecystitis which necessitates prompt diagnosis and management due to its rapid clinical course and high mortality rate.

Gas-Containing Biliary Calculi: Case Series and a Systematic Review.

BACKGROUND: Cholelithiasis is a common gallbladder finding leading to cholecystitis in 7% of cases. Sonographic imaging or computed tomography scans are commonly employed for the diagnosis of benign gallbladder disease. Air within the gallbladder might carry various diagnoses. As opposed to pathologic air in the gallbladder seen in emphysematous cholecystitis, gas-containing gallstones are no more pathological than the exclusive presence of gallstones. In the present report, we review the incidence, physiology, typical characteristics, and clinical significance of gas-containing gallstones within the gallbladder. METHODS: We performed an institutional review of all patients with benign gallbladder disease over the past 16 years (2005 to 2021) to identify patients with gas-containing gallstones in the gallbladder. We performed a review of the literature following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) to identify all reported cases of patients with gas-containing biliary calculi within the gallbladder. RESULTS: Our institutional review identified 5 patients with gas-containing biliary calculi in 1252 consecutive cholecystectomies; 4 of which had cholecystitis, while 1 was an incidental finding. Our review of the literature identified 30 manuscripts documenting 54 unique patients with gas-containing biliary calculi. None of these patients had consequential pathology related to gas in the stones other than that caused by the gallstones (ie, biliary colic and cholecystitis). CONCLUSIONS: Gas-containing biliary calculi are uncommon. How gas finds itself within gallstones within the gallbladder is not entirely clear. Gas-containing gallstones should not be interpreted as free gas within the gallbladder or within an abscess.

Case report: Whole genome sequence of Clostridium perfringens JUM001 causing acute emphysematous cholecystitis.

A strain of Clostridium perfringens was isolated from the bile sample of a patient with emphysematous cholecystitis who underwent a laparoscopic cholecystectomy, followed by treatment with meropenem and recovery. Metagenomic analysis of the bile sample showed that 99.73% of the bile microbiota consisted of C. perfringens, indicating that C. perfringens JUM001 was the causative pathogen of acute emphysematous cholecystitis in this patient. Complete genome sequencing showed that C. perfringens JUM001 contained a circular chromosome of 3,231,023 bp and two circular plasmids, pJUM001-1 of 49,289 bp and pJUM001-2 of 47,855 bp. JUM001 was found to possess a typing toxin gene, plc, but no other typing toxin genes, indicating that its toxinotype is type A. The plasmids pJUM001-1 and pJUM001-2 belonged to the pCP13-like and pCW3-like families of plasmids, respectively, which are characteristic conjugative and archetypical plasmids of C. perfringens. Phylogenetic analysis showed that JUM001 was closely related to C. perfringens strain JXNC-DD isolated from a dog in China. To our knowledge, this is the first report of whole-genome sequences of a clinical isolate of C. perfringens causing acute emphysematous cholecystitis.

Indirect cholecystoduodenal fistula via hepatoduodenal ligament secondary to gangrenous cholecystitis: a case report.

BACKGROUND: Cholecystoduodenal fistula is an infrequent complication of gallbladder diseases. In the majority of cases, the fistula is formed by direct communication between the gallbladder and duodenum due to gallstone impaction in the gallbladder neck. We herein report a rare case of indirect cholecystoduodenal fistula via the hepatoduodenal ligament secondary to gangrenous cholecystitis. CASE PRESENTATION: An 80-year-old woman suspected of having emphysematous cholecystitis by a previous doctor was referred to our hospital for urgent surgery. The initial diagnosis based on additional examinations was gangrenous cholecystitis penetrating the hepatoduodenal ligament. Since she did not complain of signs of peritonitis and was taking an anticoagulant medicine, we avoided surgery and selected percutaneous gallbladder drainage (PTGBD) instead. Contrast imaging of the PTGBD tube and upper endoscopy identified the indirect cholecystoduodenal fistula via the hepatoduodenal ligament. Despite repeated attempts at endoscopic fistula closure using clips, the fistula did not close successfully. We therefore performed laparoscopic cholecystectomy and fistula closure. The postoperative clinical course was uneventful, and she left the hospital on postoperative day 15. The resected gallbladder contained small black stones, and a histological examination revealed gangrenous cholecystitis with no malignant signatures. CONCLUSION: We encountered a rare case of indirect cholecystoduodenal fistula via the hepatoduodenal ligament secondary to gangrenous cholecystitis that was successfully treated by laparoscopic cholecystectomy and fistula closure. It is important to recognize the possible formation of indirect cholecystoduodenal fistula in cases of gangrenous cholecystitis penetrating the hepatoduodenal ligament.

Emphysematous Pyelonephritis and Emphysematous Cholecystitis: A Result of Uncontrolled Type 2 Diabetes.

Background: Emphysematous pyelonephritis (EPN) is a life-threatening necrotizing infection that results in the presence of gas in the renal parenchyma, collecting system, and surrounding tissues. Up to 95% of patients with EPN have underlying uncontrolled diabetes mellitus. Emphysematous cholecystitis (EC) is a necrotizing infection defined by the presence of gas in the gallbladder. Concurrent presentation of EPN and EC is limited to anecdotal cases in the literature. Case Report: We present the case of a 44-year-old female who arrived at the emergency department with signs of septic shock and diffuse abdominal pain. Diagnosis of EPN and EC was confirmed. Because the patient did not improve after aggressive medical therapy and percutaneous drainage and cholecystostomy, she was taken to surgery for emergency nephrectomy and cholecystectomy. Conclusion: In unusually extensive and severe cases of EPN, medical and minimally invasive procedures are not enough to control the infection. More aggressive management, including emergency surgery, should be implemented in selected patients who present with refractory septic shock associated with extensive disease.

Synchronous presentation of acute cholecystitis and acute appendicitis successful treatment in one step laparoscopic procedure. A case series and literature review.

INTRODUCTION: Hundreds of thousands of cholecystectomies and appendectomies are performed in the United States annually. Due to the prevalence of cholecystitis and appendicitis, a subset of patients will require both operations. The limited literature describing these patients supports a laparoscopic approach over open surgery; consistent with the advantages of laparotomy over open surgery in the treatment of each condition individually. CASE PRESENTATION: We report two cases where a patient presented with cholecystitis and appendicitis simultaneously. An abdominal computer tomography (CT) scan revealed the presence of the two diagnoses, which was then confirmed by an abdominal ultrasound. A four-access port was utilized for simultaneous appendectomy and cholecystectomy. DISCUSSION: A review of the literature indicates that simultaneous infection with appendicitis and cholecystitis is rare, and thus clinical presentation, lab work, and imaging studies are all needed to support such a diagnosis. Potential findings on imaging in these patients may include distended gallbladder with thickened wall and fluid-filled dilated appendix with mural enhancement. In the event that both clinical presentation and further work-up indicate both pathologies, laparoscopic intervention is suitable. A four-access port is deemed the conservative approach to dealing with such cases. CONCLUSION: Finding a single diagnosis responsible for a patient's illness is a high priority in an acute care setting, a concept known as diagnostic parsimony. However, it is inevitable that very common illnesses will be comorbid in a subset of patients, and physicians should be prepared to consider contemporaneous illness in the isolated circumstances it is warranted.

Emphysematous Cholecystitis Secondary to Fusobacterium nucleatum.

Fusobacterium nucleatum may be implicated in cases of emphysematous cholecystitis (EC) and carries a high mortality risk, especially in individuals with heart disease, renal insufficiency, and underlying malignancy. Fusobacterium infections are rarely detected in the setting of cholecystitis possibly due to the difficulty with properly culturing the bacteria. We describe a case of a patient with EC in whom blood cultures were positive for growth of F. nucleatum in one of two samples. The patient was treated with empiric antibiotic therapy consisting of metronidazole and cefepime. In patients with EC and negative cultures, it is possible that they may have an undetected infection with fusobacteria, which carries a high mortality risk. As such, clinicians should maintain a high degree of suspicion of obligate anaerobic infection in patients who have negative blood culture for growth in the setting of EC and consider continuation of adequate antimicrobial coverage.

Emphysematous cholecystitis: A deadly disguise of a common culprit.

Emphysematous cholecystitis is a critical differential diagnosis for physicians to consider when evaluating patients with acute abdomen. Patients who are unable to undergo emergency surgery can benefit from percutaneous cholecystostomy.

Marbelization of the gallbladder, a variant of acute gangrenous cholecystitis.

Cholelithiasis can present from a milder form of biliary colic to a more severe and complicated one like empyema gallbladder and a lesser-known variant of gangrenous gallbladder called marbleization of the gallbladder. The clinical signs and symptoms are similar to acute cholecystitis. Diabetes mellitus could have a role in the process of marbleization. Diagnosing marbleization of the gall bladder is not easy preoperatively. Computerized tomography is a better diagnostic modality when compared to laboratory investigations. Urgent cholecystectomy is the only option, and there is no role of conservative treatment. We report a case of a 36-year-old man with newly diagnosed Diabetes Mellitus diagnosed initially as acute cholecystitis and managed conservatively. He did not respond to treatment and hence underwent cholecystectomy and intraoperatively was found to have marbleization of the gall bladder.

Septic shock with emphysematous cholecystitis and disseminated infection caused by hypervirulent Klebsiella pneumoniae capsular genotype K2-ST65 in a Japanese man with diabetes mellitus: A case report.

Hypervirulent Klebsiella pneumoniae capsular genotypes K1 and K2 are common pathogens responsible for community-acquired liver abscesses and invasive infections especially in East Asia. We report a Japanese man with diabetes mellitus who rapidly developed emphysematous cholecystitis and fulminant disseminated infection with life-threatening multiple organ-system failure due to K. pneumoniae K2 strains belonging to sequence type 65. In East Asia, clinicians should be aware of fulminant infections caused by hypervirulent K2 strains in patients with community-acquired K. pneumoniae infections. Further epidemiological studies are warranted to elucidate the clinical features associated with the virulence K. pneumoniae K2 strains.

Emphysematous cholecystitis during the treatment of heat stroke.

BACKGROUND: During a heat stroke, microvascular injury may occur as a result of thermal damage and systemic hypoperfusion. We present a case of an older woman who experienced emphysematous cholecystitis during a treatment of heat stroke. CASE PRESENTATION: A 91-year-old woman presented unconscious with a blood pressure, pulse, and core temperature of 73/48 mmHg, 135 bpm, and 39.8°C, respectively. The patient was diagnosed with heat stroke. Twenty-two hours after arrival, the patient fell into septic shock. We diagnosed emphysematous cholecystitis and performed an emergency cholecystectomy. As the bile culture was positive for Clostridium perfringens, meropenem was administered. The patient was transferred for rehabilitation 32 days after admission. CONCLUSIONS: Emphysematous cholecystitis can present during a treatment of heat stroke. An abdominal X-ray examination should be performed during treatment of heat stroke in the acute phase regardless of the physical assessment.

Emphysematous Cholecystitis and Necrotizing Pancreatitis: Unusual Combination of Critical Pathology in a Healthy Young Patient.

Emphysematous cholecystitis (EC) is a rare form of severe cholecystitis, more common among old, frail males, with comorbidities like diabetes mellitus and peripheral vascular disease. The coexistence of emphysematous cholecystitis with necrotizing pancreatitis is extremely uncommon and in the literature, though it has been reported, no case was of a young patient like the one we are describing. He was treated with laparoscopic cholecystectomy, and his pancreatitis managed conservatively.

Emphysematous cholecystitis following routine colonoscopy.

Cholecystitis is a rare sequela of colonoscopy, the relationship between which has not yet been defined. This case study reviews a rural elderly patient who developed right upper quadrant pain following routine colonoscopy. He developed emphysematous cholecystitis, which required laparoscopy with conversion to open via Kocher's incision and underwent a subtotal cholecystectomy due to the severity of necrosis and inflammation. He had an uncomplicated recovery. Colonoscopy is an important diagnostic procedure, the most common complications of which are haemorrhage and perforation. There are less than 10 cases of associated cholecystitis and no reports of emphysematous cholecystitis. The hypothesized pathogenesis is dehydration and lithogenesis associated with traumatic translocation of organisms, however, no definitive correlation has been determined. Due to the potential health impact, cholecystitis cannot be excluded regarding post-colonoscopy abdominal pain, however, the correlation between procedure and pathology remains unclear.

Safety and Efficacy of Percutaneous Cholecystostomy for Emphysematous Cholecystitis.

OBJECTIVE: The objective of the study was to evaluate the safety and efficacy of percutaneous cholecystostomy (PC) in treating critically ill patients with emphysematous cholecystitis who were deemed poor surgical candidates. MATERIALS AND METHODS: The Institutional Review Board exemption was obtained for this retrospective study. Patients with emphysematous cholecystitis who were deemed to be poor operative candidates by the treating surgeon and underwent PC placement between May 2008 and April 2017 at a single institution were identified through a medical records search. Demographics, laboratory values, imaging data, procedural technique, complications, hospitalization course, clinical outcome, and survival data were obtained. RESULTS: Ten consecutive patients were included, with a mean age of 75.0 ± 12.2 years, including six men and four women. The most common comorbidity was diabetes (60%, 6/10) followed by hypertension (40%, 4/10). Intraluminal or intramural gas as well as gallbladder wall thickening were noted in all patients. Procedure technical success rate was 100%. There was a complete resolution of symptoms in 90% (9/10) of patients at a mean of 2.9 ± 1.4 days post-procedure. Thirty-day survival rate was 90% (9/10); one patient died on the 6th post- procedure day from sepsis. Two more deaths occurred within a year after PC from unrelated causes. About 50% (5/10) of patients underwent elective cholecystectomy at a median interval of 69 days post-procedure. In 40% (4/10) of patients, cholecystostomy was the definitive treatment, with tube removal at a median of 140 days post- procedure. CONCLUSION: PC appears to be a safe and generally effective alternative management option in patients with emphysematous cholecystitis that is considered very high risk for surgery.

Colecistitis enfisematosa: presentación de tres casos / Emphysematous cholecystitis: a report of three cases

Antecedentes: la colecistitis enfisematosa (CE) es una forma de presentación infrecuente de la colecistitis aguda. Material y métodos: presentecedentes patológicos, mientras que los otros eran diabéticos. A todos se les realizó tomografía computarizada (TC). Dos pacientes fueron sometidos a colecistectomía videolaparoscópica (CL) con buena evolución, mientras que en un caso se realizó colecistostomía percutánea (CP). Discusión: la CE se refiere a la presencia de gas en la luz o en la pared de la vesícula biliar. La tasa de morbilidad es del 50%. Los pacientes suelen padecer diabetes, pero puede presentarse en pacientes más jóvenes sin factores de riesgo. La TC es el método de elección para el diagnóstico. El tratamiento definitivo es la CL, aunque la CP es otra opción válida. Conclusión: la CL se considera un enfoque eficaz y seguro para el tratamiento de la CE.

Background: Emphysematous cholecystitis (EC) is a rare presentation of acute cholecystitis. Material and methods: We report three cases of EC in two men and one woman between 55 and 79 years. One of the patients was otherwise healthy while the other two were diabetics. A computed tomography (CT) scan was performed in all the cases. Two patients underwent video-assisted laparoscopic cholecystectomy with favorable outcome and one patient underwent percutaneous cholecystostomy. Discussion: Emphysematous cholecystitis is characterized by the presence of gas in the gallbladder lumen or wall. Mortality rate is 50%. Most patients are diabetics, but EC may present in younger patients without risk factors. Computed tomography scan is the method of choice for the diagnosis. Cholecystectomy is indicated as definite treatment, but percutaneous cholecystostomy may be a valid option. Conclusions: Laparoscopic cholecystectomy and antibiotics are effective and safe to treat.