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J Emerg Trauma Shock. 2017 Apr-Jun; 10(2): 85–86.
PMCID: PMC5357877

Diagnosis of emphysematous cholecystitis with bedside ultrasound in a septic elderly female with no source of infection

Dear Editor,

Emphysematous cholecystitis (EC) is a rare form of acute cholecystitis characterized by air in the gallbladder wall or lumen. Diagnosis is made through computed tomography (CT), however, unstable patients may not be able to obtain emergent imaging.

A 67-year-old female with no history presented to the emergency department (ED) with a week of worsening mental status. She was minimally responsive, and vital signs included a pulse of 132, respiratory rate of 12, and a temperature of 35.4°C. Laboratories revealed a white blood cell count of 48 k/uL and a hemoglobin of 3.8 g/dL. Liver enzymes, chest X-ray, and urinalysis were normal. Bedside ultrasound (US) demonstrated a distended gallbladder with gallstones, a thickened wall, and pericholecystic fluid, all obscured by an echogenic band with variable acoustic shadowing [Figures [Figures11 and and2].2]. Intravenous fluids, broad-spectrum antibiotics, and transfusion were initiated. When her condition improved, an abdominal CT identified an air-fluid level in the gallbladder, consistent with EC [Figure 3].

Figure 1
Right upper quadrant ultrasound revealing gallbladder wall thickening, a large gallstone, and abundant heterogeneous sludge within the gallbladder
Figure 2
Right upper quadrant ultrasound demonstrating air within the gallbladder, represented by a bright echogenic stripe with “dirty shadowing” beneath
Figure 3
Abdominal computed tomography scan reveals air within the gallbladder, consistent with emphysematous cholecystitis

EC is frequently caused by Clostridia, Escherichia coli, and Klebsiella. Patients present with right upper quadrant pain, fever, and vomiting. Treatment requires antibiotics and surgical intervention, as mortality ranges from 15% to 25%, compared to four percent for uncomplicated acute cholecystitis. Cholecystectomy is the treatment of choice.[1] Diagnosis is based on clinical presentation and demonstration of gas in the gallbladder wall or lumen. X-ray has a sensitivity of up to 95%, however, changes on US and CT are visible earlier. US demonstrates air in the lumen or in the wall, appearing as highly echogenic reflection with posterior shadowing and reverberation artifact.[2] Despite the high specificity of US (95%), sensitivity is poor. Contrast-enhanced abdominal CT remains the modality of choice, providing the location and extent of air and fluid with high specificity and sensitivity.[3] In a patient such as this, however, bedside US rapidly identifies pathology and guides management in an easily reproducible manner without leaving the ED.

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1. Carrascosa MF, Salcines-Caviedes JR. Emphysematous cholecystitis. CMAJ. 2012;184:E81. [PMC free article] [PubMed]
2. Katagiri H, Yoshinaga Y, Kanda Y, Mizokami K. Emphysematous cholecystitis successfully treated by laparoscopic surgery. J Surg Case Rep 2014. 2014:pii: Rju027. [PMC free article] [PubMed]
3. Miyahara H, Shida D, Matsunaga H, Takahama Y, Miyamoto S. Emphysematous cholecystitis with massive gas in the abdominal cavity. World J Gastroenterol. 2013;19:604–6. [PMC free article] [PubMed]

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