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Abdomen » Hepatobiliary
Perforated emphysematous cholecystitis with abscess in the omental bursa
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Author(s) :
Taco Geertsma, MD
 
Presentation 80 year old male patient with severe pain in the right upper abdomen and fever. The patients medical history is unremarkable without previous surgery or an ERCP.
 
 
 
Caption: Longitudinal image of the gallbladder, patient is in supine position
Description: There is air in the gallbladder fundus. There is a thin irregular gallbladderwall. There is debris in the dependant part of the gallbladder
 
 
 
Caption: Image of the gallbladder with the patient in slight left decubitus position
Description: The arrow points to the air in the gallbladder that displaces according to the patients position
 
 
 
Caption: Longitudinal image of the gallbladder
Description: The arrow points to stones in the gallbladder neck. A large part of the gallbladder is obscured by the acoustic shadow caused by the air.
 
 
 
Caption: Transverse image of the upper abdomen
Description: The red arrow (A) points to the fluid filled gallbladder. The green arrow (B) points to an abscess
 
 
 
Caption: Longitudinal image left upper quadrant in the mid clavicular line
Description: There is a fluid and air filled abscess impressing the left liver lobe
 
 
 
Caption: CT scan at the level of image 4
Description: The left arrow points to the gallbladder with air in the fundus. The right arrow points to the air and fluid filled abscess in the omental bursa impressing the contrast filled stomach
 
 
 
Caption: CT scan at the level of image 5
Description: There is a large fluid and air filled abscess impressing the left liver lobe
 
Differential Diagnosis Air in the gallbladder and biliary tract can be caused by an abnormal communication between the digestive tract and the biliary tree. Possible causes are
- a previous papillotomy
- previous surgery such as a choledochoduodenostomy
- perforation (often a gallstone) to the digestive tract
The other cause of air in the gallbladder and sometimes in the biliary ducts, is an emphysematous cholecystitis. In most cases of an empysematous cholecystitis however there is no air in the bile ducts, because the cystic duct is often obstructed. This makes a differentiation possible
In this case there is an emphysematous cholecystitis
 
Final Diagnosis Perforated emphysematous cholecystitis with abscess in the omental bursa
 
Discussion

Emphysematous cholecystitis is an acute infection of the gallbladder caused by gas-forming organisms

Several factors can account for an emphysematous cholecystitis

Gallstones

In most of the patients with an emphysematous cholecystitis gallstones are found, often with obstruction of the cystic duct. However an emphysematous cholecystitis can also be found in cases of an acalculous cholecystitis

Vascular compromise

An emphysematous cholecystitis is more common in elderly patients with atherosclerosis. Diabetes is not uncommon. Although gallstones are more common in females, an emphysematous cholecystitis is more frequently found in males

Infection with gas-forming organisms

In about 1/3  of the cases clostridium perfringens is found. Other organisms are E. Coli and Klelbsiella 

The mortality rate of an emphysematous cholecystitis is much higher than in cases of a non emphysematous cholecystitis.

Because of gallbladder wall ischemia there is a high risk of perforation of the wall. In this case an abscess has formed in the omental bursa.

The ultrasound findings of an emphysematous cholecystitis are.

Highly reflective air in the wall or the lumen of the gallbladder
Air in the wall must be differentiated from calcium which can be found in a porcelain gallbladder. If in doubt X ray can help differentiating between the two
An  ill defined wall is not uncommon.
Thickened bile and or stones are a frequent findings

For more examples of an emphysematous cholecystitis  visit www.ultrasoundcases.info


 
Case References

Konno K, Ishida H, Naganuma H, Sato M, Komatsuda T, Sato A, Ishida J, Sakai T,Watanabe S. Emphysematous cholecystitis sonographic findings. Abdom Imaging 2002 Mar-Apr;27(2):191-5.

Gill KS, Chapman AH, Weaton MJ The changing face of emphysematous cholecystitis Br. J Radiol. 1997 Oct;70(838):986-91.

Alan A Bloom, Prospere Remy Emphysematous Cholecystitis Emedicine


 
Follow Up Surgery in a case of an emphysematous cholecystitis has a very high complication rate. A percutaneous drainage procedure under ultrasound guidance was performed of both the gallbladder and the abscess.
The patient recovered quickly and an ultrasound examination performed a few weeks later showed complete disappearance of the abscess and a small shrunken gallbladder
 
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