The Changing Face of Emphysematous Cholecystitis

1. The Changing Face of Emphysematous Cholecystitis K S Gill, A H Chapman, M J Weston Department of Radiology, St. James’s University hospital, Beckett Street, Leeds LS9 7TF,UK. The British Journal of Radiology, 70(1997),986-991 The British Institute of Radiology

2. Emphysematous Cholecystitis • a variant of acute cholecystitis • characterized by the presence of gas in the gall bladder lumen, wall orpericholecystic tissues in the absence of an abnormal communication betweenthe biliary system and the gastrointestinal tract

3. Background • diagnosis has relied on the plain abdominal radiograph (AXR) • thereare no clinical features to separate this condition from simple acutecholecystitis • high mortality and morbidity associated withemphysematous cholecystitis has emphasized the importance ofearly recognition to enable immediate surgical intervention

4. Objective • To describe the investigators’ own experience of this condition, using newer and more sensitive imaging modalities

5. Methodology • Computer search of all hospital radiological cases of past 5 years (1400 bed inner city teaching hospital) • Keyword: “emphysematous cholecystitis” • 8 confirmed cases

6. Findings

7. Findings • 5 males and 3 females with average age of 69.4 years ( 54-83 yrs) • On admission, 4 pxs were apyrexial and 3 out of them remained so thoughout the course • Only 1 px was appearing unwell and the rest (7) were described as “looks well” or “comfortable” • 4 pxs had WBC above 11 x 109 1 -1 • 4 pxs had WBC less than 8x 109 1 -1 • Diagnosis was made using imaging in all cases

8. Table 2. Imaging and Clinical Outcome

9. Findings Plain abdominal radiograph • 7 pxs had an abdominal radiograph (AXR) • 3 cases were normal • 1 case was reported to be suspicious of biliary tract gas on AXR • Subsequent US confirmed emphysematous cholecytitis

10. Findings US • all cases were subjected to US • Primary diagnosing modality in 5 cases • Failed to diagnose other 3 cases • CT was required

11. Findings CT • was diagnostic in three cases where US failed and confirmed positive US finding in a further case • Average delay before dx was 2 days from admission • Delay was less (< 1 day avg.) if dx was made with US • 4 day delay average with CT because CT was only requested subsequent to non-diagnostic US exam

12. Treatment

13. Initial Antiobiotics resulted in complete resolution of symptoms, allowing discharge and return for open operations after a few weeks 3 Interval cholecystectomy 2 signs and symptoms were not resolving, but both px were comfortable 3 acute surgery w/ an ave of 4 days delay after admission 1 (Patient 5) settled clinically, but still underwent acute surgery because of unchanged US findings after 4 days 8 patients 1 conservative treatment (IV and Antibiotics) Remained well 18 months later without having had cholecystectomy 1 developed hemiparesis before planned elective biliary surgery Died of complications related to cardiovascular disease

14. Patient 5 • The only one in whom imaging influenced the decision of management, the decision being based on clinical progess in all other cases

15. All 6 of the surgical patients had either inflammation, empyema, or frank gangere of the gallbladder • Those who under went interval surgery • Had the least severe pathological changes, acute, chronic or subacute cholecystitis