eMedicine Specialties > Gastroenterology > Biliary

Emphysematous Cholecystitis

Author: Alan A Bloom, MD, Associate Clinical Professor of Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Gastroenterology, Veterans Affairs Hospital, Bronx
Coauthor(s): Prospere Remy, MD, Assistant Professor of Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Internal Medicine, Bronx-Lebanon Hospital Center
Contributor Information and Disclosures

Updated: Jul 11, 2008

Introduction

Background

Emphysematous cholecystitis is an acute infection of the gallbladder wall caused by gas-forming organisms. First described by Stoltz in 1901, it was thought to be a rare disorder. However, as a result of improved imaging techniques, it is now being described with increasing frequency.

Pathophysiology

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. 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.

Gallstones

Gallstones are observed in 28-80% of patients with emphysematous cholecystitis. Impaction of stones in the cystic duct leads to localized edema of the wall, which contributes to the vascular compromise of the gallbladder. Nevertheless, emphysematous cholecystitis in the presence of acalculous cholecystitis is well established. 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.^1,2

Impaired immune protection

Diabetes mellitus is detected in 38-55% patients with emphysematous cholecystitis, and the mean age of patients is 59 years. Both 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. While 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.

Rare associations

Cases have been reported following endoscopic retrograde cholangiopancreatography (ERCP) and following the use of sunitinib in the treatment of gastrointestinal stromal tumor (GIST).

See related CME at New Guidelines Address Management of Common Bile Duct Stones.

Frequency

United States

Emphysematous cholecystitis occurs infrequently. Reports in the surgical literature indicate that emphysematous cholecystitis develops in approximately 1% of all cases of acute cholecystitis. 

An estimated 500,000 cholecystectomies are performed per year in the United States. Assuming all patients with emphysematous cholecystitis come to surgery, this would indicate that 5000 cholecystectomies are performed per year for emphysematous cholecystitis. While the number of patients who are treated successfully without surgery is certainly small, the number of patients who die without surgery is unknown.

Mortality/Morbidity

Overall mortality rates vary from 15-25%. These rates are 5 times the operative mortality rates for nonemphysematous cholecystitis. In addition to the septic character of the disease, comorbidities attendant to advanced age and diabetes mellitus also add to the risk of mortality.²

Race

No racial predilection has been described.

Sex

Unlike other biliary tract disorders, emphysematous cholecystitis occurs more frequently in men; men comprise 65-70% of all patients with emphysematous cholecystitis.^3,2

Age

The disease occurs more commonly in older patients. In one study, the mean age of 20 patients was 59 years, and, in another study, 59% of patients were aged 60 years or older.

Clinical

History

The typical patient is a man older than 60 years, often with type II diabetes mellitus. Otherwise, the clinical scenario does not differ significantly from that observed in acute calculous cholecystitis.

• Pain is localized to the right upper quadrant and often radiates to the back. It is unrelated to position or physical activity.
• 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.

Physical

• Physical examination usually reveals an elderly patient with fever and tachycardia.
• Abdominal examination shows tenderness in the right upper quadrant.
• An enlarged tense gallbladder may be noted, best demonstrated by light palpation.
• Bowel sounds are diminished or absent, especially if peritonitis has supervened.
• Jaundice is unusual unless a concomitant common duct obstruction and/or intrahepatic disease is present.
• Transient relief of right upper quadrant pain followed by the appearance of peritoneal signs is the hallmark of perforation.

Causes

See Pathophysiology.

• Search for CME/CE on This Topic »

• Clostridial Cholecystitis (Gastroenterology)
• Cholecystitis, Acute (Radiology)
• Cholecystitis (Gastroenterology)