(P02) Emphysematous Cholecystitis in an Immunocompromised Patient

Chief Complaint : Abdominal pain and nausea

History of Present Illness : 41-year-old male with past medical history of sarcoidosis (on daily methotrexate and steroids) presenting for right upper quadrant (RUQ) pain and vomiting x 2 months, increasing in severity x 1 day. Patient states that he has been having pain “every time” he eats, but that his pain improves without intervention within minutes. He presented to the ER today because he had an episode of this similar pain, but increased in severity in comparison to previous episodes. Episode has now been unrelenting and has been associated with nausea and multiple episodes of nonbilious, nonbloody vomiting. Of note, he has been told he should receive a right upper quadrant ultrasound to evaluate, but he has been unable to see them due to scheduling issues.

Pertinent Physical Exam: Patient speaking in full sentences, without respiratory distress. Patient uncomfortable appearing, lying in stretcher. Epigastric tenderness and RUQ tenderness present with palpation, positive Murphy’s sign. No CVA tenderness. No overlying skin changes to the abdomen or back.

Pertinent Laboratory Data: No leukocytosis, no anemia. ALT increased to 80U/L, AST increased to 157U/L. Alk Phos increased to 203U/L. Total bilirubin increased to 1.8mg/dL, direct to 0.8mg/dL. Lipase within normal limits.

Case Discussion: Acute cholecystitis is defined as inflammation of the gallbladder, oftentimes due to cystic duct obstruction by gallstones (acute calculous cholecystitis). Less predominantly, patients may also present with acalculous cholecystitis, although this is more likely in critically ill patients. Characteristic clinical features of cholecystitis include RUQ pain, positive Murphy sign, and fever. The preferred modality of imaging is a RUQ ultrasound, which is superior to CT in its ability to accurately demonstrate gallbladder distension, edema and pericholecystic fluid, although CT is better at investigating adjacent organ systems that may be impacted by the inflammation.

Complications of acute cholecystitis include gangrenous cholecystitis, emphysematous cholecystitis, gallstone ileus, gallbladder perforation, biliary-enteric fistula and pyogenic liver abscess. Of particular concern is the development of emphysematous cholecystitis, which although rare, is a life-threatening form of acute cholecystitis characterized by the presence of air within the gallbladder wall caused by gas forming bacteria (i.e. E. coli and Clostridium)

Emphysematous cholecystitis is preceded by vascular compromise in the gallbladder wall, usually due to occlusion of the cystic artery as a result of increased pressure within the gallbladder environment, oftentimes in the setting of external compression or heavy cholelith burden. The vascular compromise rapidly progresses to ischemia of the gallbladder wall, followed by necrosis that weakens the structural integrity of the wall and limits immune surveillance, thereby allowing for the proliferation of gas forming bacteria within the gallbladder. Risk factors include vascular compromise, (i.e. prolonged hyperglycemia (Diabetes) or vascular disease), immunosuppression, recent abdominal procedures or trauma.

The patient in question has an autoimmune inflammatory disorder (sarcoidosis) and is on immunosuppressants (daily steroids and methotrexate), raising his risk for developing emphysematous cholecystitis. He received broad spectrum antibiotics and within 48 hours, had undergone a laparoscopic cholecystectomy, which is the treatment modality for patients who are good surgical candidates.

References and Acknowledgements (Optional): Mhamdi S, Mhamdi K. Emphysematous Cholecystitis. N Engl J Med. 2019 Aug 22;381(8):e14. doi: 10.1056/NEJMicm1814551.

Wu JM, Lee CY, Wu YM. Emphysematous cholecystitis. Am J Surg. 2010 Oct;200(4):e53-4. doi: 10.1016/j.amjsurg.2010.01.027.

Maddu K, Phadke S, Hoff C. Complications of cholecystitis: a comprehensive contemporary imaging review. Emerg Radiol. 2021 Oct;28(5):1011-1027. doi: 10.1007/s10140-021-01944-z. Epub 2021 Jun 10.