Emphysematous Cholecystitis

Emphysematous cholecystitis is acute gallbladder inflammation with gas forming organisms, producing gas in the lumen, wall or pericholecystic tissue. It is a surgical emergency with higher rates of gangrene and perforation than ordinary acute cholecystitis.

It accounts for about 1% of acute cholecystitis. About 20% to 50% of cases occur in diabetes, men are affected more than women (about 70%), and gallstones are absent in a fifth to a third of cases. Mortality is about 15% to 25%, compared with about 4% for uncomplicated acute cholecystitis. Gangrene occurs in about 75% and perforation in 15% to 20%.

Organisms are Clostridium perfringens, Escherichia coli, Klebsiella, other Gram negative bacilli and anaerobes, often mixed.

Pathophysiology.

Cystic artery ischaemia (atherosclerosis, diabetic microvascular disease) permits gas forming bacteria to grow in the devitalised gallbladder wall. Fermentation of glucose produces carbon dioxide and hydrogen.

Right upper quadrant pain, fever, nausea and vomiting, which are often milder than expected, especially in diabetes. Crepitus on palpation is rare. Sepsis, peritonitis and shock indicate gangrene or perforation.

Red flags.

• Sepsis or shock.
• Peritonitis.
• Rising lactate.
• Diabetic ketoacidosis.

CT is the most sensitive test and shows gas in the lumen, wall or pericholecystic tissue and the extent of complications. Ultrasound shows a bright echogenic focus with posterior reverberation artefact. A plain radiograph may show gas in the gallbladder fossa, sometimes with an air fluid level. Send blood cultures, full blood count, C-reactive protein, lactate, glucose and liver tests.

Differential diagnosis.

• Gas from a biliary enteric fistula or sphincterotomy.
• Gangrenous cholecystitis without gas.
• Liver abscess.
• Perforated viscus.
• Gallstone ileus.

Resuscitate, give antibiotics at once and plan emergency cholecystectomy within 24 to 48 hours (laparoscopic if feasible, with a low threshold to convert). Percutaneous cholecystostomy is an option for patients at high surgical risk, followed by interval cholecystectomy.

• Piperacillin-tazobactam: 4.5 g IV every 6 hours for 4 to 7 days after source control; maximum 18 g daily; monitor renal function, blood counts and cultures; reduce for creatinine clearance under 40 mL/min.
• Meropenem (alternative for resistant Gram negative organisms): 1 g IV every 8 hours for 4 to 7 days after source control; maximum 6 g daily; monitor renal function and seizures; reduce for creatinine clearance under 50 mL/min.
• Clindamycin (added for Clostridium toxin suppression in severe sepsis, when cover is not otherwise sufficient): 600 to 900 mg IV every 8 hours; usually 3 to 5 days; maximum 2.7 g daily; monitor for Clostridioides difficile infection and liver function; no renal adjustment.

Control glucose with an insulin infusion in diabetes and correct fluid, electrolyte and acid base disturbance.

Monitoring. Vital signs, lactate, glucose and inflammatory markers daily; drain output after cholecystostomy.

Referral and escalation. Emergency general or hepatobiliary surgery, interventional radiology and critical care.

Special groups. Diabetic and older patients can deteriorate quickly with few symptoms.