RUQ pain, septic, unstable BP • Xray of the Week
Figure 1. What is the important finding on these images.
A. HIDA scan showing liver, common bile duct, small bowel
B. Magnified view HIDA scan showing common bile duct (green arrow) and duodenum (blue arrow). Note that tracer is not present in the gallbladder due to cystic duct obstruction.
C. Abdominal CT showing enlarged gallbladder with gas in the gallbladder wall (yellow arrow) and cholelithiasis (red arrow).
Emphysematous cholecystitis is a rare, life-threatening form of acute cholecystitis that occurs when gas-producing bacteria invade the gallbladder wall and cause necrosis (1). Air accumulates in the wall as seen in figure 2C, which can be attributed to gallbladder ischemia, tissue infarction, drugs, abdominal trauma, or incompetence of the sphincter of Oddi (1). Emphysematous cholecystitis typically occurs in diabetic men and puts patients at increased risk of gallbladder perforation (2).
Emphysematous cholecystitis has echogenic foci with reverberation artifact on ultrasound, but ultrasound is less sensitive and specific than CT scan (3). The appearance of air in the lumen on ultrasound is also known as the “ring-down artifact” or “dirty shadowing” (4). Emphysematous cholecystitis can be distinguished from acute cholecystitis on CT due to the presence of gas in the gallbladder wall or lumen (1,5). On CT, emphysematous cholecystitis may also demonstrate pericholecystic inflammatory changes, intrahepatic abscess, gallbladder wall thickening, cholelithiasis, and intraperitoneal free air (1,3). On MRI, emphysematous cholecystitis shows intraluminal gas and intramural necrosis as well as gallstones in the neck of the gallbladder (1). Emphysematous cholecystitis may also present with the “champagne sign” or effervescent gallbladder sign on MRI, which refers to the foci of gas in the wall (1).
Treatment of emphysematous cholecystitis includes broad-spectrum antibiotics and emergency cholecystectomy, although patients not suitable for surgery may undergo temporary percutaneous cholecystostomy (2,3).
Click here to see what was done for this patient:
Treatment of Emphysematous Cholecystitis
Safwan M, and Penny SM. Emphysematous Cholecystitis: A Deadly Twist to a Common Disease. Journal of Diagnostic Medical Sonography, vol. 32, no. 3, May 2016, pp. 131–37. doi:10.1177/8756479316631535
Yen WL, Hsu CF, Tsai MJ. Emphysematous cholecystitis. Tzu Chi Medical Journal. 2016;28(1):37-38. doi:10.1016/j.tcmj.2015.12.001
Sunnapwar A, Raut AA, Nagar AM, Katre R. Emphysematous cholecystitis: Imaging findings in nine patients. Indian J Radiol Imaging. 2011;21(2):142-146. doi:10.4103/0971-3026.82300
Aherne A, Ozaki R, Tobey N, Secko M. Diagnosis of emphysematous cholecystitis with bedside ultrasound in a septic elderly female with no source of infection. J Emerg Trauma Shock. 2017;10(2):85-86. doi:10.4103/JETS.JETS_75_16
Chen, Ming-Yu, et al. Emphysematous Cholecystitis in a Young Male without Predisposing Factors: A Case Report. Medicine, vol. 95, no. 44, Nov. 2016, p. e5367. doi:10.1097/MD.0000000000005367
Amara Ahmed is a medical student at the Florida State University College of Medicine. She serves on the executive board of the American Medical Women’s Association and Humanities and Medicine. She is also an editor of HEAL: Humanism Evolving through Arts and Literature, a creative arts journal at the medical school. Prior to attending medical school, she graduated summa cum laude from the Honors Medical Scholars program at Florida State University where she completed her undergraduate studies in exercise physiology, biology, and chemistry. In her free time, she enjoys reading, writing, and spending time with family and friends.
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Kevin M. Rice, MD is the president of Global Radiology CME
Dr. Rice is a radiologist with Renaissance Imaging Medical Associates and is currently the Vice Chief of Staff at Valley Presbyterian Hospital in Los Angeles, California. Dr. Rice has made several media appearances as part of his ongoing commitment to public education. Dr. Rice's passion for state of the art radiology and teaching includes acting as a guest lecturer at UCLA. In 2015, Dr. Rice and Natalie Rice founded Global Radiology CME to provide innovative radiology education at exciting international destinations, with the world's foremost authorities in their field. In 2016, Dr. Rice was nominated and became a semifinalist for a "Minnie" Award for the Most Effective Radiology Educator.
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