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Emphysematous cholecystitis

Emphysematous cholecystitis

Emphysematous cholecystitis is an uncommon and life threatening form of acute cholecystitis that is characterized by the presence of gas in the lumen and wall of the gallbladder 1. The presence of gas may be detected elsewhere in the biliary tract or adjacent structures in addition to gas in the gallbladder wall. Emphysematous cholecystitis is a surgical emergency requiring urgent cholecystectomy or cholecystostomy due to a high risk of gallbladder gangrene and/or perforation. Unlike typical cholecystitis, in which gallstones (cholelithiasis) is the major pathogenesis, the cause of emphysematous cholecystitis is related to ischemia of the gallbladder wall, which may be related to atherosclerotic changes in vessels, and infection with gasforming bacteria, such as Clostridium perfringens, Klebsiella species, and Escherichia coli 2. Emphysematous cholecystitis occurs in about 1% to 3% of all cases of acute cholecystitis but carries significantly higher morbidity and mortality 1. The prevalence of emphysematous cholecystitis is three times higher in males compared to females. Individuals most susceptible to emphysematous cholecystitis are elderly people with diabetes mellitus and those with a weak immune system 3. Diabetes is noted to be present in 30% to 75% of patients with this disorder. The mean age of diagnosis is around 60. There is also an association with peripheral vascular disease and immunosuppression. The mortality due to this life-threatening form of cholecystitis is reported to be around 15% to 25% 4. Furthermore, the incidence of gallbladder perforation is 5 times higher than in typical cholecystitis 5.

Due to the high mortality rate of emphysematous cholecystitis, prompt diagnosis and intervention are imperative. Radiography, ultrasonography, and computed tomography of the abdomen can provide much information for early diagnosis of this disease 6. Making the emphysematous cholecystitis diagnosis often is straightforward on plain abdominal radiography. The typical radiological finding in emphysematous cholecystitis is air in the lumen or wall of the gall bladder, or adjacent soft tissue. Cholecystectomy is the standard treatment for emphysematous cholecystitis. Temporary percutaneous cholecystotomy can be another choice in a few select patients 7. Concurrent broadspectrum antibiotic therapy is also necessary 7. In severely ill patients, percutaneous cholecystostomy with broad-spectrum antibiotics may be an alternative choice for treatment.

Emphysematous cholecystitis causes

Four pathogenetic factors are proposed in the development of emphysematous cholecystitis.

Vascular compromise of the gallbladder

In most cases, the cystic artery is the sole arterial supply of the gallbladder. Occlusion or stenosis results in compromised viability of the gallbladder, in which arteriosclerosis is the usual causative abnormality, although the condition has been described after an embolic event. The evidence that vascular insufficiency is a root cause of emphysematous cholecystitis is circumstantial, that is, association with diabetes mellitus, greater incidence in males, high frequency of gangrene, and occurrence in older patients. However, exceptions exist for each of these.

Vascular compromise of the cystic artery renders the gallbladder ischemic and facilitates the proliferation of gas-forming organisms and bacterial translocation in the devitalized tissue with low oxygen saturation. Bacteriocidal bile is rendered alkaline, facilitating infection of the bile. Histopathologic reviews of emphysematous gallbladders reveal a higher incidence of endarteritis obliterans compared with the typical acute cholecystitis secondary to cholelithiasis.

A case of emphysematous cholecystitis that developed following hepatic artery embolization appeared to substantiate the theory that vascular compromise is the main pathogenic factor 8. In another report, gallbladder torsion progressed to emphysematous cholecystitis, probably due to ischemic necrosis (secondary to torsion) facilitating infection and translocation of gas-forming bacteria 9.

Emphysematous cholecystitis has also been reported as an adverse event caused by sunitinib, administered for the treatment of gastrointestinal stromal tumor (GIST), probably due to the thromboembolic side effect of this class of drugs (vascular endothelial growth factor [VEGF] receptor inhibitors) 10.

Cholelithiasis

Gallstones are observed in 28-80% of patients with emphysematous cholecystitis. Impaction of stones in the cystic duct leads to localized edema of the gallbladder wall, which contributes to the vascular compromise of the gallbladder. Nevertheless, emphysematous cholecystitis in the presence of acalculous cholecystitis is well established, occurring nearly 3 times more frequently in the emphysematous form, suggesting that there is a basic difference in the pathogenesis between emphysematous cholecystitis and acute cholecystitis secondary to gallstones 11. Indeed, the proportion of patients with acalculous cholecystitis in association with emphysematous cholecystitis exceeds that of patients with ordinary acute calculous cholecystitis.

These observations raise doubt about the role of gallstones in the pathogenesis of emphysematous cholecystitis 12.

Impaired immune protection

Diabetes mellitus is detected in 38-55% patients with emphysematous cholecystitis, and the mean age of patients is 59 years. Both the metabolic abnormality and older age probably contribute to the increased risk of infection.

Infection with gas-forming organisms

Microorganisms commonly isolated are clostridial species, Escherichia coli, and Klebsiella species. Less frequently, enterococci and anaerobic streptococci are among the other organisms detected. Although the intramural gas observed in patients with emphysematous cholecystitis seems to result from gas-forming bacteria, whether these bacteria represent the primary cause of the disorder or are secondary invaders remains unclear. Concomitant emphysematous cholecystitis and emphysematous pyelonephritis raise the possibility of septic seeding of the gallbladder wall. Infectious complications following endoscopic retrograde cholangiopancreatography (ERCP) have also been reported 13.

Micro-organisms that have been isolated in patients with emphysematous cholecystitis include the following:

  • Clostridia
  • Klebsiella
  • Escherichia coli
  • Enterococci
  • Anaerobic streptococci

In an analysis of bile in 109 cases of emphysematous cholecystitis, 95 of 109 (87%) had a positive culture, of which 46% were clostridial species (79% of the clostridial cultures grew Clostridium welchii and 33% grew E coli, often as a copathogen with Clostridia 11.

In a separate series of 20 patients with emphysematous cholecystitis, Tellez et al reported gallbladder culture results in which E coli (Escherichia coli) grew in 40%, Bacteroides fragilis in 30%, Clostridium perfringens in 20%, and Proteus vulgaris, Aerobacteraerogenes, as well as Klebsiella, Streptococcus, Staphylococcus, and Enterococcus species in 40% 14.

The bacteriologic patterns of simple (ie, nonemphysematous) cholecystitis are vastly different—only 12% of the positive cultures of typical acute cholecystitis grew clostridia 11. Thus, there is nearly a 4-fold difference in the incidence of clostridial infection in patients with emphysematous cholecystitis compared with those with ordinary acute cholecystitis 11.

It is thought that these organisms acquire pathogenicity when they proliferate in a devascularized gallbladder. Specifically, clostridium produces several different exotoxins, the most prevalent being oxygen-stable lecithinase-C, an alpha-toxin which is hemolytic, tissue-necrotizing and lethal 15. This alpha-toxin induces profound shock via increased capillary permeability, cardiotoxicity, and leukocyte dysfunction.

Emphysematous cholecystitis symptoms

Despite the potentially lethal nature of this disease, patients with emphysematous cholecystitis—typically a man older than 60 years, often with type 2 diabetes mellitus—often have deceptively mild clinical findings that are frequently indistinguishable from acute cholecystitis. The insidious nature of this disease may mislead the clinician, and the patient may unsuspectingly rapidly deteriorate with sudden cardiovascular collapse and even death.

The most common symptoms initially are right upper quadrant pain and fever. The pain is localized to the right upper quadrant and often radiates to the back, but it is unrelated to position or physical activity. The patient may also complain of generalized abdominal pain consistent with peritonitis. Nausea and vomiting occur less frequently.

In addition, an antecedent history of self-limited episodes of pain may be present. However, the clinician must be aware that elderly patients may develop acute intra-abdominal disorders with little or no localizing symptoms or signs 16.

The physical examination usually reveals an elderly patient with fever and tachycardia, who may be obtunded depending on the presence of septic shock. These individuals may also be hypotensive, depending on the severity of the disease. If concomitant choledocholithiasis or common duct obstruction and/or intrahepatic disease is present, the patients can also appear jaundiced.

When evaluating the abdominal region, there is generally tenderness in the right upper quadrant, but there may also be diffuse tenderness consistent with peritonitis. In certain cases, there could be overlying erythema of the right side secondary to perforation of the gallbladder with intraperitoneal abscess 17. In addition, an enlarged tense gallbladder may be noted, which is best demonstrated by light palpation. Bowel sounds are diminished or absent, especially if peritonitis has supervened. Transient relief of right upper quadrant pain followed by the appearance of peritoneal signs is the hallmark of perforation.

Major fluid sequestration (ie, “third-spacing” of fluid), florid septic shock, or peritonitis may occur as later clinical presentations.

Emphysematous cholecystitis diagnosis

Two levels of differential diagnosis should be considered: clinical and radiologic.

The clinical differential diagnosis is that of acute cholecystitis (nonemphysematous), both calculous and acalculous, as well as bacterial sepsis, peritonitis, and abdominal sepsis.

The radiologic differential diagnosis is that of finding gas in the biliary tree, which may be due to a biliary-enteric fistula (spontaneous or surgical); may occur after endoscopic retrograde cholangiopancreatography (ERCP), especially following a sphincterotomy; or may be due to cholangitis caused by gas-forming organisms 18. Imaging studies are the key diagnostic maneuvers.

Although urinalysis, chest radiography, and electrocardiography add little to establish a diagnosis, these studies should be obtained as part of the preoperative assessment of the patient.

Laboratory studies

Complete blood cell count with differential. Patients have leukocytosis that is, at times, strikingly high, but this feature cannot differentiate clostridial cholecystitis (emphysematous cholecystitis) from simple cholecystitis.

Liver function tests

Liver tests results are usually normal or slightly elevated (eg, aspartate aminotransferase [AST], alanine aminotransferase [ALT]), reflecting the patient’s febrile state and potentially reflecting concurrent choledocholithiasis (seen in up to 10% of patients). Very abnormal liver test results, especially elevated alkaline phosphatase (ALP), bilirubin, or gamma-glutamyl transpeptidase (GGTP), suggest a common duct obstruction or intrahepatic disease.

Serum glucose

Serum glucose can also be elevated, because many patients with emphysematous cholecystitis are also diabetic.

Abdominal radiography

The key radiographic finding in emphysematous cholecystitis is air inside the gallbladder and/or in the gallbladder area (seen in 95% of patients) or in the biliary tree (15%) 14.

Abdominal radiographs show the classic picture of a gallbladder wall containing gas (see Figure 1). The gallbladder is often fluid-filled, and gas that has leaked into its lumen collects in the least dependent portion 19. The absence of a gas-filled gallbladder wall on an abdominal radiograph does not exclude a diagnosis of emphysematous cholecystitis 20.

Inflammation and gas formation may extend to the pericholecystic tissues and extrahepatic ducts. This picture has been regarded as specific for emphysematous cholecystitis, but the sensitivity is unknown.

Pneumoperitoneum may be present, but this is rare. Occasionally, pneumobilia can be the sole radiographic finding 11.

With the advent of other imaging techniques, especially computed tomography (CT) scanning, the importance of plain radiographs of the abdomen has declined.

Changes noted on CT scans and ultrasonograms of the abdomen can be observed before the classic abnormalities are visible on plain abdominal radiograph 12. Furthermore, the presence of abnormal findings on a plain film of the abdomen may indicate advanced disease 12 as the classic picture observed on abdominal radiographs is believed to represent a late phase in the evolution of emphysematous cholecystitis and may presage a poorer outcome.

Abdominal radiographs are less sensitive than ultrasonograms and computed tomography (CT) scans 21 and may be negative in up to 60% of cases. This consideration has altered both the diagnostic workup and the surgical options; early diagnosis requires CT scanning, and the presence or absence of gas outside the gallbladder will influence the choice of the surgical approach 12.

Evaluation with abdominal computed tomography (CT) scanning is now considered the primary imaging modality to confirm acute emphysematous cholecystitis, as it is the most sensitive and specific imaging modality for identifying gas in the gallbladder lumen or wall 22. CT scanning demonstrates emphysematous changes in the gallbladder wall that are diagnostic of this condition and is highly sensitive for tiny bubbles of air which may not be seen on ultrasonography. CT scanning can also provide precise information regarding the location and extent of air and fluid collections, such as extension into the pericholecystic tissues and the hepatic ducts. Gas in the peritoneum indicates perforation 23.

CT scanning should be performed early in the evaluation when the clinical picture warrants, and it is indicated in cases in which an ultrasonographic or abdominal radiographic evaluation is equivocal. Initial use of CT scanning may eliminate the need for further imaging studies and facilitates appropriate clinical management 24.

Figure 1. Emphysematous cholecystitis abdominal radiograph

Emphysematous cholecystitis abdominal radiograph

Footnote: Gas within the gallbladder indicated by star. Gas within gallbladder wall indicated by solid line. Free gas indicated by open and closed arrows.

Emphysematous cholecystitis ultrasound

Abdominal ultrasound is the most common imaging modality currently employed to visualize the gallbladder, especially in those patients with the clinical suspicion of acute cholecystitis. This modality helps detect acute emphysematous cholecystitis earlier than plain abdominal radiography and identifies the condition in 90-95% of cases.

Emphysematous cholecystitis is classically described ultrasonographically in 3 stages 25.

  • Stage 1: Gas is present in the gallbladder lumen. There is a dense band of hyperreflective echoes with distal reverberations when the gallbladder is full of gas or a band of reverberations in the gas-filled portion of the gallbladder with the usual signs of cholecystitis in the bile-filled portion when the gallbladder is partially full of gas.
  • Stage 2: Gas is present in the gallbladder wall. There is an area of high reflectivity in the gallbladder wall with reverberations that may change position with patient movements or a bright hyperreflective ring emanating from the entire gallbladder circumference.
  • Stage 3: Gas is present in the pericholecystic tissue and is seen inside the gallbladder, within its wall and outside the gallbladder in the surrounding tissues, indicating gangrene and perforation.

Effervescent gallbladder

In some cases, there may be multiple tiny echogenic foci in the gallbladder lumen, arising from the dependent part of the gallbladder and “floating” to the nondependent wall, reminiscent of bubbles rising in a glass of champagne 26.

Ring-down effect/comet tail

Curvilinear gaseous artifacts in the gallbladder, the “ring-down effect” or “comet tail,” are diagnostic of emphysematous cholecystitis, but the frequency with which these are observed is not clear 27.

Disadvantages

One disadvantage of ultrasonography is that extensive gallbladder wall gas can be interpreted as nonvisualization of the gallbladder, resulting in false-negative results from the scans 12. In addition, the characteristic ultrasonographic findings of intraluminal or intramural gas may be highly echogenic reflectors on ultrasonography, which can be mistaken for a porcelain gallbladder or stones adherent to the gallbladder wall. These findings are not diagnostic of emphysematous cholecystitis. The alert clinician questions the paradoxical absence (ie, ultrasonographic nonvisualization) of a gallbladder in the clinical setting of a patient who likely has gallbladder disease 28.

Although ultrasonography is highly specific (90-95%) to diagnose acute clostridial cholecystitis (emphysematous cholecystitis), its sensitivity is lower. Computed tomography scanning may help in certain equivocal cases. However, if the diagnosis is made by ultrasonography, the patient should proceed to surgery without delay and CT scanning is unwarranted.

Figure 2. Emphysematous cholecystitis ultrasound

Emphysematous cholecystitis ultrasound

Footnote: Cholelithiasis (gallstones) is present. The gallbladder wall is thickened. Within the anterior wall, there is hyperechogenic curvilinear foci causing dirty shadowing, suggestive of intramural gas. This is seen to move with patient positioning. There is pericholecystic fluid. Sonographic Murphy’s sign is positive. The common bile duct is dilated (maximal diameter 12mm). No choledocholithiasis appreciated. Normal liver echotexture and echogenicity. No focal liver lesion. The portal and hepatic veins are patent. Ascites is present. In this case, the acute surgical team were made aware of the findings immediately after the scan. The patient was too unwell with a long list of comorbities for general anesthesia and cholecystectomy and hence went onto to have a ultrasound guided cholecystostomy. Bile culture was positive for Klebsiella and Enterobacter species.

[Source 29 ]

Emphysematous cholecystitis treatment

Management of emphysematous cholecystitis is surgical. Antibiotics and fluid replacement are started immediately to stabilize the patient, but because of the risk of perforation and its impact on survival, clinicians tend to proceed to surgery with deliberate speed. Overall, surgical mortality rates vary from 15% to 25%.

Antibiotics

Broad-spectrum antibiotics should be initiated immediately preoperatively and can be continued postoperatively until the patient clinically improves. Then these agents can be tailored according to the bacteriologic samples obtained during the surgical procedure.

Intravenous antibiotics of choice are those that have beta-lactamase inhibitor activity or combinations that provide coverage for anaerobic and gram-negative organisms. A good choice is ampicillin/sulbactam (Unasyn) or piperacillin/tazobactam (Zosyn) with or without metronidazole (Flagyl) depending on the level of Bacteroides coverage desired.

Antibiotic regimens are suggested with the following caveats: (1) antibiotics are not definitive therapy for this condition, and (2) antibiotic regimens should be evaluated in light of changing bacterial sensitivities, changing antibiotic options, and changing patient characteristics.

Fluid management

Fluid replacement and correction of electrolyte deficits and metabolic imbalances should be initiated in preparation for surgery. It is to be emphasized that these temporary and preparatory maneuvers are not intended to reverse the basic disease process.

Open or laparoscopic cholecystectomy

Traditionally, early open cholecystectomy was performed. Laparoscopic cholecystectomy for acute emphysematous cholecystitis was first described in 1994, and experience with this technique continues to increase. Although laparoscopic cholecystectomy is feasible, the number of cases does not allow valid comparisons with open cholecystectomy for mortality and complications. A preoperative diagnosis of perforation would likely preclude a laparoscopic approach, thereby requiring a preoperative computed tomography (CT) scanning or magnetic resonance imaging (MRI) of the abdomen 30.

As long as fundamental surgical principles are maintained (and depending on the patient and surgeon skill/comfort level) laparoscopic cholecystectomy is a safe and effective treatment for this disease process 31. The surgeon should be aware that higher conversion rates have been reported due to the anatomic distortion caused by acute inflammation 32, although with current techniques, emphysematous cholecystitis can be treated initially as a laparoscopic procedure while maintaining a low threshold for conversion. Due to the degree of inflammation, the surgeon should consider postoperative drainage of the gallbladder fossa (eg, Jackson-Pratt drain) to potentially decrease the risk of postoperative fluid collections and abscess formation.

Percutaneous cholecystostomy

This procedure is an option mainly for patients in such poor clinical condition that they cannot tolerate general anesthesia. Cholecystostomy (done under local anesthesia by the interventional radiologists under ultrasonographic guidance) is considered a temporary measure to control sepsis. Once the sepsis is controlled and the patient improves, an interval (ie, 4-6 weeks later) cholecystectomy can be performed for definitive therapy.

Common bile duct exploration

If the patient has concurrent common bile duct stones, common bile duct exploration can be done transcystically or via choledochotomy, open or laparoscopic, to clear the common bile duct. An alternative choice is to refer the patient postoperatively to the biliary endoscopist for ERCP to clear the common bile duct of stones.

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