Gastrointestinal
Gastrointest. Radiol 4, 153-155 (1979)
Radiology
Diagnosis of Emphysematous Choleeystitis by Computerized Tomography G a r y D. P o l e y n a r d 1 a n d R o n a l d D. H a r r i s 2 Departments of Gastroenterology 1 and Radiology 2 Scripps Clinic Medical Institutions, La Jolla, California, USA
Abstract. A case of e m p h y s e m a t o u s cholecystitis is presented in which c o m p u t e r i z e d t o m o g r a p h y helped to c o n f i r m the diagnosis a n d the extent of disease preoperatively. This u n u s u a l disorder is briefly reviewed a n d the clinical a n d r a d i o g r a p h i c findings are discussed.
Key words: E m p h y s e m a t o u s cholecystitis, diagnosis -
C o m p u t e r i z e d t o m o g r a p h y , acute a b d o m e n .
E m p h y s e m a t o u s cholecystitis is a n u n u s u a l f o r m of acute i n f l a m m a t o r y r e a c t i o n in the g a l l b l a d d e r wall caused by g a s - f o r m i n g bacteria. It is characterized r a d i o g r a p h i c a l l y by the r a d i o l u c e n t o u t l i n e of gas w i t h i n the g a l l b l a d d e r l u m e n a n d / o r wall. We report a case in which the diagnosis was c o n f i r m e d a n d the extent of disease was clearly demo n s t r a t e d by c o m p u t e r i z e d axial t o m o g r a p h y .
Case Report An 85-year-old man was admitted to the hospital with abdominal distention. He had been followed for several years with moderately severe but stable congestive heart failure. Ten days before admission he noted the onset of abdominal distention and ill-defined, constant discomfort throughout the right abdomen. Constipation had been partly relieved by enemas, and a small amount of stool and gas had been passed on the day of admission. He had not complained of chills, fever, or darkening of his urine. The patient's temperature was 38~ C. Abdominal examination revealed mild tympany, hypoactive bowel sounds, and slight tenderness throughout the right abdomen without signs of peritoneal irritation, Cardiomegaly and a mitral regurgitation murmur were noted. Address reprint requests to." Ronald D. Harris, M.D., Department
of Radiology, Scripps Clinic, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA.
The white blood cell count was 12,800/cu mm with a left shift. Serum amylase, bilirubin, and urinalysis were normal. Supine and upright plain films of the abdomen (Fig. 1) demonstrated a right upper quadrant oval gas-filled structure which contained a gas-fluid level in the upright position. In addition, mottled gas bubbles were seen in the surrounding tissues. These findings suggested the diagnosis of emphysematous cholecystitis with abscess formation in the gallbladder bed. Computerized axial tomography (CAT) confirmed the presence of gas within the gallbladder as well as within its wall (Fig. 2 A) and in the intrahepatic biliary ducts (Fig. 2 B). The CAT examination also demonstrated an abscess confined to the gallbladder bed (Fig. 2 B). At operation a gangrenous gallbladder and subhepatic abscess were found. The abscess was evacuated and a cholecystectomy was performed without incident. Pathological examination confirmed the diagnosis of gangrenous cholecystitis and cholelithiasis. Culture of the abscess and the gallbladder yielded Clostridium perfringens. The patient's postoperative recovery was prompt.
Discussion S y m p t o m s o f e m p h y s e m a t o u s cholecystitis do n o t differ significantly f r o m those of the m o r e usual acute cholecystitis. I n spite of the a l m o s t c o n s t a n t finding of a g a n g r e n o u s gallbladder, there are often n o welllocalized signs o f p e r i t o n e a l i r r i t a t i o n on physical e x a m i n a t i o n [l]. W h e n c o m p a r e d to o r d i n a r y acute cholecystitis, there is a reversal of female p r e d o m i n a n c e (73%) to that of male (71%). A n increased frequency of acalculus cholecystitis (28% versus 10%), g a n g r e n e (74% versus, 2.5%), p e r f o r a t i o n (21% versus 4.5%), a n d mortality, especially in patients less t h a n 60 years old (15% versus 1.4%), is also seen [1, 2]. I n addition, diabetes mellitus is often associated with e m p h y s e m a tous variety (38 %) b u t bears n o r e l a t i o n s h i p to perfor a t i o n or m o r t a l i t y [1, 3]. The m i c r o b i a l agent is u s u a l l y one of the gasf o r m i n g bacteria with clostridia species, as in the pres-
9
0364-2356/79/0004-0153 $01.00 1979 Springer-Verlag N e w Y o r k Inc.
154
G.D. Poleynard and R.D. Harris: E m p h y s e m a t o u s Cholecystitis
Fig. 1, A. Film of the right upper a b d o m e n shows an oval gas-containing gallbladder (arrows). Mottled gas bubbles are seen around the gallbladder bed. B. Upright radiograph of the right upper quadrant demonstrates the gas-bile level within the gallbladder. Again noted are the mottled gas bubbles in the subhepatic abscess (arrows)
Fig. 2. A. Computerized t o m o g r a m of the a b d o m e n shows the gas-fluid level in the gallbladder as well as gas within the gallbladder wall (arrow). B~ Scan of the a b d o m e n shows gas in the abscess in the subhepatic area (arrow) as well as some gas within some intrahepatic biliary radicles
G.D. Poleynard and R.D. Harris: Emphysematous Cholecystitis
ent case, or Escherichia coli and streptococci being the frequently isolated organisms. It is thought that ischemia may play an important role in the pathogenesis as gangrene is usually a facilitative factor rather than a result of infection. This is supported by the finding of arteriolar narrowing in some cases as well as a tendency for clostridia to be more invasive in the presence of ischemia [3]. It is speculative in the present case as to whether the mild circulatory compromise of the patient's congestive heart failure had any role in the pathogenesis. The diagnosis is typically suspected when plain films show the lucent outline of gas in the gallbladder lumen, its wall, or adjacent tissues or biliary ducts [4]. The differential diagnosis includes incompetent sphincter of Oddi, intestinal-biliary anastomosis, biliary intestinal fistula, duodenal ulcer perforation into the bile duct, and lipomatosis [2, 5]. The diagnosis or confirmation of calculus gallbladder disease is often best made by ultrasound. However, as gas inhibits the transmission of sound waves, echography would not have been of use in the present case and probably would be of little help in emphysematous cholecystitis generally. Computerized tomography was chosen as the best means of confirming the diagnosis preoperatively and establish-
155
ing the presence and extent of abscess formation. The ability of computerized tomography to measure tissue densities by the determination of attenuation coefficients as well as the excellent anatomic display makes this tool extremely efficient in such an evaluation. In the present case not only was the diagnosis of emphysematous cholecystitis confirmed, but the abscess formation was defined, allowing the surgeon to anticipate his surgical approach.
References 1. Mentzer RM, Golden GT, Chandler JG, Horsley JS IIl: A comparative appraisal of emphysematous cholecystitis. Am J Surg 129:10-15, 1975 2. Sarmiento RV: Emphysematous cholecystitis: Report of four cases and review of the literature. Arch Surg 93.'1009-1014, 1966 3. Bonnabeau RC Jr, Tenekjian V, Djadalizadeh M. : Emphysematous cholecystitis: Report of a case. Am Surg 42.'352-354, 1976 4. Hegner CF : Gaseous pericholecystitis with cholecystitis and cholelithiasis. Arch Surg 22:993-1000, 1931 5. Felson B, Spitz HB: Pneumoperitoneum and right upper quadrant gas in a diabetic man. JAMA 236:2789-2790, 1976
Received: June 29, 1978; accepted: August 9, 1978
Gastrointest. Radiol 4, 153-155 (1979)
Radiology
Diagnosis of Emphysematous Choleeystitis by Computerized Tomography G a r y D. P o l e y n a r d 1 a n d R o n a l d D. H a r r i s 2 Departments of Gastroenterology 1 and Radiology 2 Scripps Clinic Medical Institutions, La Jolla, California, USA
Abstract. A case of e m p h y s e m a t o u s cholecystitis is presented in which c o m p u t e r i z e d t o m o g r a p h y helped to c o n f i r m the diagnosis a n d the extent of disease preoperatively. This u n u s u a l disorder is briefly reviewed a n d the clinical a n d r a d i o g r a p h i c findings are discussed.
Key words: E m p h y s e m a t o u s cholecystitis, diagnosis -
C o m p u t e r i z e d t o m o g r a p h y , acute a b d o m e n .
E m p h y s e m a t o u s cholecystitis is a n u n u s u a l f o r m of acute i n f l a m m a t o r y r e a c t i o n in the g a l l b l a d d e r wall caused by g a s - f o r m i n g bacteria. It is characterized r a d i o g r a p h i c a l l y by the r a d i o l u c e n t o u t l i n e of gas w i t h i n the g a l l b l a d d e r l u m e n a n d / o r wall. We report a case in which the diagnosis was c o n f i r m e d a n d the extent of disease was clearly demo n s t r a t e d by c o m p u t e r i z e d axial t o m o g r a p h y .
Case Report An 85-year-old man was admitted to the hospital with abdominal distention. He had been followed for several years with moderately severe but stable congestive heart failure. Ten days before admission he noted the onset of abdominal distention and ill-defined, constant discomfort throughout the right abdomen. Constipation had been partly relieved by enemas, and a small amount of stool and gas had been passed on the day of admission. He had not complained of chills, fever, or darkening of his urine. The patient's temperature was 38~ C. Abdominal examination revealed mild tympany, hypoactive bowel sounds, and slight tenderness throughout the right abdomen without signs of peritoneal irritation, Cardiomegaly and a mitral regurgitation murmur were noted. Address reprint requests to." Ronald D. Harris, M.D., Department
of Radiology, Scripps Clinic, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA.
The white blood cell count was 12,800/cu mm with a left shift. Serum amylase, bilirubin, and urinalysis were normal. Supine and upright plain films of the abdomen (Fig. 1) demonstrated a right upper quadrant oval gas-filled structure which contained a gas-fluid level in the upright position. In addition, mottled gas bubbles were seen in the surrounding tissues. These findings suggested the diagnosis of emphysematous cholecystitis with abscess formation in the gallbladder bed. Computerized axial tomography (CAT) confirmed the presence of gas within the gallbladder as well as within its wall (Fig. 2 A) and in the intrahepatic biliary ducts (Fig. 2 B). The CAT examination also demonstrated an abscess confined to the gallbladder bed (Fig. 2 B). At operation a gangrenous gallbladder and subhepatic abscess were found. The abscess was evacuated and a cholecystectomy was performed without incident. Pathological examination confirmed the diagnosis of gangrenous cholecystitis and cholelithiasis. Culture of the abscess and the gallbladder yielded Clostridium perfringens. The patient's postoperative recovery was prompt.
Discussion S y m p t o m s o f e m p h y s e m a t o u s cholecystitis do n o t differ significantly f r o m those of the m o r e usual acute cholecystitis. I n spite of the a l m o s t c o n s t a n t finding of a g a n g r e n o u s gallbladder, there are often n o welllocalized signs o f p e r i t o n e a l i r r i t a t i o n on physical e x a m i n a t i o n [l]. W h e n c o m p a r e d to o r d i n a r y acute cholecystitis, there is a reversal of female p r e d o m i n a n c e (73%) to that of male (71%). A n increased frequency of acalculus cholecystitis (28% versus 10%), g a n g r e n e (74% versus, 2.5%), p e r f o r a t i o n (21% versus 4.5%), a n d mortality, especially in patients less t h a n 60 years old (15% versus 1.4%), is also seen [1, 2]. I n addition, diabetes mellitus is often associated with e m p h y s e m a tous variety (38 %) b u t bears n o r e l a t i o n s h i p to perfor a t i o n or m o r t a l i t y [1, 3]. The m i c r o b i a l agent is u s u a l l y one of the gasf o r m i n g bacteria with clostridia species, as in the pres-
9
0364-2356/79/0004-0153 $01.00 1979 Springer-Verlag N e w Y o r k Inc.
154
G.D. Poleynard and R.D. Harris: E m p h y s e m a t o u s Cholecystitis
Fig. 1, A. Film of the right upper a b d o m e n shows an oval gas-containing gallbladder (arrows). Mottled gas bubbles are seen around the gallbladder bed. B. Upright radiograph of the right upper quadrant demonstrates the gas-bile level within the gallbladder. Again noted are the mottled gas bubbles in the subhepatic abscess (arrows)
Fig. 2. A. Computerized t o m o g r a m of the a b d o m e n shows the gas-fluid level in the gallbladder as well as gas within the gallbladder wall (arrow). B~ Scan of the a b d o m e n shows gas in the abscess in the subhepatic area (arrow) as well as some gas within some intrahepatic biliary radicles
G.D. Poleynard and R.D. Harris: Emphysematous Cholecystitis
ent case, or Escherichia coli and streptococci being the frequently isolated organisms. It is thought that ischemia may play an important role in the pathogenesis as gangrene is usually a facilitative factor rather than a result of infection. This is supported by the finding of arteriolar narrowing in some cases as well as a tendency for clostridia to be more invasive in the presence of ischemia [3]. It is speculative in the present case as to whether the mild circulatory compromise of the patient's congestive heart failure had any role in the pathogenesis. The diagnosis is typically suspected when plain films show the lucent outline of gas in the gallbladder lumen, its wall, or adjacent tissues or biliary ducts [4]. The differential diagnosis includes incompetent sphincter of Oddi, intestinal-biliary anastomosis, biliary intestinal fistula, duodenal ulcer perforation into the bile duct, and lipomatosis [2, 5]. The diagnosis or confirmation of calculus gallbladder disease is often best made by ultrasound. However, as gas inhibits the transmission of sound waves, echography would not have been of use in the present case and probably would be of little help in emphysematous cholecystitis generally. Computerized tomography was chosen as the best means of confirming the diagnosis preoperatively and establish-
155
ing the presence and extent of abscess formation. The ability of computerized tomography to measure tissue densities by the determination of attenuation coefficients as well as the excellent anatomic display makes this tool extremely efficient in such an evaluation. In the present case not only was the diagnosis of emphysematous cholecystitis confirmed, but the abscess formation was defined, allowing the surgeon to anticipate his surgical approach.
References 1. Mentzer RM, Golden GT, Chandler JG, Horsley JS IIl: A comparative appraisal of emphysematous cholecystitis. Am J Surg 129:10-15, 1975 2. Sarmiento RV: Emphysematous cholecystitis: Report of four cases and review of the literature. Arch Surg 93.'1009-1014, 1966 3. Bonnabeau RC Jr, Tenekjian V, Djadalizadeh M. : Emphysematous cholecystitis: Report of a case. Am Surg 42.'352-354, 1976 4. Hegner CF : Gaseous pericholecystitis with cholecystitis and cholelithiasis. Arch Surg 22:993-1000, 1931 5. Felson B, Spitz HB: Pneumoperitoneum and right upper quadrant gas in a diabetic man. JAMA 236:2789-2790, 1976
Received: June 29, 1978; accepted: August 9, 1978
