Journal of Emergencies, Trauma, and Shock
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LETTERS TO EDITOR  
Year : 2017  |  Volume : 10  |  Issue : 2  |  Page : 85-86
Diagnosis of emphysematous cholecystitis with bedside ultrasound in a septic elderly female with no source of infection


Department of Emergency Medicine, Division of Ultrasound, Kings County Hospital Center, Downstate University Hospital, Brooklyn, NY 11203, USA

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Date of Submission20-Oct-2016
Date of Acceptance01-Feb-2017
Date of Web Publication3-Mar-2017
 

How to cite this article:
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;10:85-6

How to cite this URL:
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 [serial online] 2017 [cited 2017 Apr 25];10:85-6. Available from: http://www.onlinejets.org/text.asp?2017/10/2/85/201588


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 [Figure 1] and [Figure 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

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Figure 2: Right upper quadrant ultrasound demonstrating air within the gallbladder, represented by a bright echogenic stripe with “dirty shadowing” beneath

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Figure 3: Abdominal computed tomography scan reveals air within the gallbladder, consistent with emphysematous cholecystitis

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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.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Carrascosa MF, Salcines-Caviedes JR. Emphysematous cholecystitis. CMAJ 2012;184:E81.  Back to cited text no. 1
    
2.
Katagiri H, Yoshinaga Y, Kanda Y, Mizokami K. Emphysematous cholecystitis successfully treated by laparoscopic surgery. J Surg Case Rep 2014;2014. pii: Rju027.  Back to cited text no. 2
    
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.  Back to cited text no. 3
    

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Correspondence Address:
Andrew Aherne
Department of Emergency Medicine, Division of Ultrasound, Kings County Hospital Center, Downstate University Hospital, Brooklyn, NY 11203
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JETS.JETS_75_16

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    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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