Emphysematous Cholecystitis

Full of Gas

Step 1: View clinicals

An 80 year old man presents with pain in the upper abdomen for 1 day, in association with anorexia and nausea. There was no history of chest pain, dyspnea, cough, or urinary or bowel symptoms. He was diagnosed with diabetes mellitus 10 years ago, which is well controlled on Metformin alone. His medical and surgical histories are otherwise unremarkable. His random capillary glucose is 280 mg/dl. Serial ECGs are found to be normal. Serum amylase, lipase, liver functions, renal functions, and electrolytes are within normal parameters.

Step 2: Order all relevant investigations

Complete blood count

WBC/DC: 13,000/mm3 (4,600-11,000) Neutrophils: 90% Hb: 12 g/dl (11-18) Platelets: 190,000/mm3 (150,000-450,000)

Plain x-ray abdomen

The plain x-ray of the abdomen reveals a hyperlucent area in the right upper quadrant.

Ultrasound abdomen

The liver appears normal, but the gallbladder is poorly visualized. Both kidneys appear normal. No intraperitoneal free fluid is present.

CT abdomen

The gallbladder is distended, while intraluminal and intramural gas is seen. No gallstones are noted, while pneumoperitoneum is not present. The remainder of the abdominal viscera appear normal.

Step 3: Select appropriate management

Conservative management
IV antibiotics
Percutaneous cholecystostomy
Start insulin

Score: ★★☆