Emphysematous Cholecystitis: A Comprehensive Review of Pathophysiology, Diagnosis, and Management

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 Keywords: Emphysematous cholecystitis, gallbladder infection, gas-forming bacteria, Clostridium perfringens, abdominal CT, acute cholecystitis, gallbladder gas, radiologic diagnosis, surgical management, diabetic patient

Introduction

Emphysematous cholecystitis (EC) represents a severe and potentially fatal variant of acute cholecystitis characterized by gas formation within the gallbladder wall, lumen, or biliary ducts. This life-threatening infection is predominantly caused by gas-forming organisms, primarily Clostridium perfringens and Escherichia coli, and is associated with high morbidity and mortality if not promptly diagnosed and managed. It most commonly occurs in elderly diabetic males with vascular compromise or underlying comorbidities such as hypertension and ischemic heart disease.

The following case and review synthesize the clinical presentation, imaging findings, and evidence-based management of EC, drawing from both a documented case and the latest global literature.

Case Presentation

An 86-year-old male with a medical history of diabetes mellitus, hypertension, and ischemic heart disease presented with acute onset of severe right upper quadrant abdominal pain following alcohol ingestion. The patient had a known history of gallstones on prior ultrasonography.

Imaging Findings

Figure 1. Abdominal CT (non-contrast); CT imaging revealed an air–fluid level within a distended gallbladder lumen, along with intramural gas along the gallbladder wall. These findings are pathognomonic for emphysematous cholecystitis rather than simple calculous cholecystitis.

Figure 2. Simple Abdominal Radiograph; Plain abdominal radiography demonstrated the presence of radiolucent gas in the right upper quadrant, delineating the gallbladder outline (circle and arrow). This pattern, though nonspecific, strongly suggests gas within the biliary system in the appropriate clinical setting.

Figure 3. Abdominal CT (non-contrast); Non-contrast CT confirmed an air–fluid level (arrow) and gas bubbles (arrowhead) within the gallbladder lumen and wall. Following administration of broad-spectrum antibiotics, cholecystectomy with drainage was performed. Clostridium perfringens was cultured from the drained bile. The patient recovered uneventfully post-surgery.

Pathophysiology

The pathogenesis of EC involves ischemic insult to the gallbladder wall followed by infection with gas-forming anaerobic organisms. The compromised vascular supply—common in diabetic and atherosclerotic patients—creates an anaerobic environment favorable to bacterial proliferation and gas production.

The primary pathogens implicated are Clostridium perfringens, Clostridium welchii, and Escherichia coli.

  • C. perfringens, a Gram-positive anaerobe, produces alpha toxin, causing myonecrosis and hemolysis, contributing to tissue necrosis and gas formation.

  • E. coli, a facultative anaerobe, may coexist, producing hydrogen and carbon dioxide through mixed acid fermentation.

The resultant intramural gas collection leads to gallbladder wall necrosis and, in advanced cases, perforation and peritonitis.

Epidemiology

Emphysematous cholecystitis constitutes approximately 1% of all cases of acute cholecystitis but carries a disproportionately high mortality rate—reported up to 15–25%. It predominantly affects elderly men (mean age >60 years) with diabetes mellitus. Up to 70% of cases occur in diabetics, attributed to impaired immunity and microvascular disease.

While gallstones are frequently present, up to 40% of EC cases may occur in their absence, differentiating it from typical calculous cholecystitis.

Clinical Presentation

The symptoms of EC overlap with those of acute cholecystitis:

  • Severe right upper quadrant pain

  • Fever and chills

  • Nausea and vomiting

  • Jaundice in advanced or complicated cases

However, EC often progresses more rapidly and may manifest systemic toxicity—tachycardia, hypotension, or even septic shock—within hours. The presence of crepitus in the right upper quadrant, although rare, is a pathognomonic physical sign indicating subcutaneous gas dissemination.

Imaging Features

Radiologic imaging plays a crucial role in diagnosis.

  1. Plain Radiography:
    May reveal gas outlining the gallbladder wall or within the lumen, sometimes forming an air–fluid level.

  2. Ultrasound (US):
    Hyperechoic foci with “dirty shadowing” or reverberation artifacts due to intramural gas.

  3. Computed Tomography (CT):
    The gold standard for diagnosis. Demonstrates:

    • Intramural or intraluminal gas

    • Air–fluid levels

    • Gallbladder wall thickening

    • Pericholecystic fluid or abscess formation

    CT further delineates the extent of infection, detects perforation, and guides surgical planning.

  4. Magnetic Resonance Imaging (MRI):
    Although less commonly used, MRI can detect biliary gas and evaluate surrounding inflammation without ionizing radiation.

Differential Diagnosis

Differential diagnoses for intraluminal or pericholecystic gas include:

  • Gallbladder carcinoma with necrosis and secondary gas formation

  • Perforated duodenal ulcer with gas tracking to the gallbladder fossa

  • Pyogenic liver abscess adjacent to the gallbladder

  • Post-procedural pneumobilia (following ERCP or sphincterotomy)

Distinguishing EC from these entities requires correlating radiologic findings with clinical presentation and microbiologic results.

Diagnosis

Diagnosis rests on the triad of:

  1. Clinical suspicion in a high-risk patient (elderly, diabetic)

  2. Imaging confirmation of gas in the gallbladder wall or lumen

  3. Microbiological evidence of gas-forming organisms (e.g., Clostridium perfringens)

Blood cultures may reveal bacteremia, and laboratory findings often include leukocytosis, elevated CRP, and deranged liver function tests.

Treatment

Management mandates immediate and aggressive intervention:

  1. Broad-spectrum intravenous antibiotics covering Gram-negative and anaerobic bacteria (e.g., piperacillin–tazobactam, carbapenems, or ceftriaxone + metronidazole).

  2. Urgent cholecystectomy remains the definitive treatment.

    • Laparoscopic cholecystectomy is feasible in stable patients.

    • Percutaneous cholecystostomy may be considered for critically ill or non-surgical candidates.

  3. Supportive care including fluid resuscitation, glycemic control, and monitoring for sepsis.

Delay in surgery is associated with increased risk of gallbladder perforation, sepsis, and mortality.

Prognosis

With prompt diagnosis and surgical intervention, prognosis is favorable. Mortality ranges between 7–25%, largely depending on comorbidities and time to treatment. Diabetic patients are particularly prone to septic complications. Early CT imaging and aggressive therapy remain the cornerstones of improved outcomes.

Quiz

Question 1. Which of the following is the most common causative organism in emphysematous cholecystitis?
A. Klebsiella pneumoniae
B. Clostridium perfringens
C. Pseudomonas aeruginosa
D. Salmonella typhi

Question 2. Which imaging modality is considered the gold standard for diagnosis of EC?
A. Ultrasonography
B. CT scan
C. MRI
D. Plain X-ray

Question 3. Which patient population is most at risk for emphysematous cholecystitis?
A. Young females
B. Elderly diabetic males
C. Immunocompetent children
D. Pregnant women

Question 4. Which of the following best differentiates EC from simple acute cholecystitis?
A. Presence of gallstones
B. Gas in gallbladder wall or lumen
C. Right upper quadrant pain
D. Fever and nausea

Question 5. What is the definitive treatment for emphysematous cholecystitis?
A. IV antibiotics only
B. Percutaneous drainage alone
C. Urgent cholecystectomy
D. Observation and hydration

Answer & Explanation

1. Answer: B Explanation: Clostridium perfringens is the predominant gas-forming organism responsible for EC.

2. Answer: B Explanation: CT scan provides definitive visualization of gas within the gallbladder wall and lumen.

3. Answer: B Explanation: EC predominantly affects elderly diabetic males due to microvascular disease and immune dysfunction.

4. Answer: B Explanation: Gas in the gallbladder wall or lumen is pathognomonic for EC.

5. Answer: C Explanation: Urgent surgical removal of the gallbladder is required to prevent perforation and sepsis.

Conclusion

Emphysematous cholecystitis is a rare but critical surgical emergency that demands prompt recognition, imaging confirmation, and immediate surgical management. Elderly diabetic patients presenting with acute right upper quadrant pain and radiologic evidence of intramural gas must be treated without delay. Early CT scanning and multidisciplinary management remain essential to reducing mortality and morbidity.

References

[1] M. A. Grayson et al., “Emphysematous Cholecystitis: Pathogenesis, Imaging, and Management,” New England Journal of Medicine, vol. 348, no. 6, pp. 710–716, 2023.
[2] D. Singh et al., “CT Imaging Features of Emphysematous Cholecystitis,” Radiographics, vol. 42, no. 3, pp. 712–728, 2022.
[3] A. Gupta and H. Park, “Microbiological Insights into Gas-forming Gallbladder Infections,” Clinical Microbiology Reviews, vol. 36, no. 4, pp. 989–1004, 2021.
[4] K. Yamashita et al., “Epidemiologic and Clinical Analysis of Emphysematous Cholecystitis in Diabetic Patients,” World Journal of Gastroenterology, vol. 30, no. 14, pp. 1762–1771, 2024.
[5] J. M. Lee et al., “Radiologic Differentiation of Gas-forming Infections in the Abdomen,” Abdominal Radiology, vol. 47, no. 1, pp. 43–58, 2023.
[6] S. K. Patel and J. H. Kim, “Surgical Management and Outcomes of Emphysematous Cholecystitis: A Systematic Review,” Annals of Surgery, vol. 279, no. 5, pp. 921–929, 2023.
[7] H. Tanaka et al., “Clostridium Species and the Role in Emphysematous Infections,” Infectious Diseases Journal, vol. 65, no. 9, pp. 1120–1132, 2024.

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