ISSN No. 1606-7754                   Vol.8 No.3 December 2000

Sub-acute presentation of emphysematous cholecystitis in a Type 2 diabetic patient

Charalambous C1, Malik RA2, Mamtora H3, Aslam R3, Young RJ4.

1Department of Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, UK.2Department of Medicine, Manchester Royal Infirmary, Oxford Road, Manchester, UK. 3Department of Radiology, Hope hospital, Salford, UK.4Department of Diabetes and Endocrinology, Hope hospital, Salford, UK

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Introduction

Emphysematous cholecystitis (EC) is a severe variety of acute cholecystitis associated with gallbladder gangrene and perforation. Patients with this condition normally present with severe abdominal pain, and are toxic requiring urgent surgical intervention. We report an unusual case of a sub-acute presentation of EC in a Type 2 diabetic patient who responded favourably to percutaneous ultrasound guided gallbladder drainage.

Case summary

A 66 year old female with Type 2 diabetes presented to the diabetes clinic with a 2 week history of upper abdominal pain and two episodes of vomiting which her general practitioner had attributed to "gastritis". Five days earlier the patient had an episode of rigors for which she was commenced on Cefadroxil for a presumed urinary tract infection. In the diabetes clinic, physical examination was found to be unremarkable except for mild tenderness in the right hypochondrium, but with no evidence of peritonism. Laboratory investigations showed an elevation in the white cell count 17.1 ´ 109 l-1 (normal range 4 -11 ´ 109), alkaline phosphatase 171 IU l-1 (10-130), gamma glutamyl transferase 103 IU l-1 (10-43), and glycated haemoglobin 10.4% (non-diabetic range <5%). Eight hours later the right hypochondrial pain increased, and she became pyrexial (38.5 OC) and she was commenced on intravenous cefuroxime 750mg three times daily and metronidazole 500mg four times daily. A plain abdominal X-ray was not performed as she proceeded immediately to an abdominal ultrasound which showed a peri-hepatic fluid collection, but the gall bladder could not be visualised. An abdominal CT scan showed a large peri-hepatic abscess, two gallstones within the gallbladder and gas in the gallbladder (Figure 1). A further ultrasound scan localised the gas to the gall bladder wall but there was no associated bile duct dilatation. She underwent ultrasound guided percutaneous drainage of the perihepatic abscess and a pig-tail catheter remained in situ which drained a total of 220ml of thick, brown fluid which grew E Coli. Her pyrexia and abdominal pain settled after three days, the pig-tail catheter was removed and she was converted to oral cefuroxime 500mg twice daily and metronidazole 400mg three times daily for a further ten days. Her concurrent obesity and poorly controlled diabetes precluded her from undergoing immediate cholecystectomy. She remains well, free of any abdominal complaints 2 years later.

Discussion

Most physicians believe that diabetic individuals are predisposed to infections and that infection limits maintenance of good glycaemic control. Whilst diabetic patients may be at increased risk of the commoner infections, they also suffer from a number of severe infections which include emphysematous pyelonephritis, perinephric abscess, malignant external otitis, rhinocerebral mucormycosis, and emphysematous cholecystitis which carry a significant morbidity and mortality.1

EC, originally described by Lobingier in 1908,2 is an extremely rare but severe form of acute cholecystitis with a high incidence of gallbladder gangrene and perforation. It predominantly3, though not exclusively,4 affects individuals with diabetes in whom emergency abdominal surgery is needed to limit intra-abdominal sepsis and the resultant high morbidity (50%) and mortality (25%).3

The most frequent pathogens are C perfringens, E Coli and B fragilis.3 Patients with this condition tend to be toxic and unwell and complications include the formation of hepatic abscess, biliary sepsis and hepatorenal failure.3,4,5 Initial investigations to diagnose this condition include abdominal X-ray and abdominal ultrasound,4 although, as in our case, they may require computerised tomography.6 Surgical intervention is usually the treatment of choice in emphysematous cholecystitis.3 A less invasive approach with percutaneous transhepatic gallbladder drainage under ultrasound guidance, followed by elective cholecystectomy and choledochotomy has recently proven to be successful.6

The sub-acute presentation in our case was exceptional, particularly as our patient had not felt that her symptoms were troublesome enough to require hospital treatment. Autonomic neuropathy secondary to diabetes could account for the lack of prominent symptoms. However, hyperglycaemia may attenuate the inflammatory response and mask the clinical picture. Also the early commencement of antibiotic therapy by the patient’s general practitioner may have influenced the clinical presentation.

An abdominal ultrasound is conventionally employed to define gall bladder pathology, particularly in EC. However, the relatively indolent nature of her condition required computerised tomography to provide higher resolution to reach an initial diagnosis.7 Furthermore, subsequent management did not involve surgical intervention, which has exclusively been the approach to treatment of this condition. Thus a relatively non-invasive approach employing ultrasound guided percutaneous gallbladder drainage resulted in complete recovery, attesting to a favourable outcome, following a relatively conservative approach. Elective cholecystectomy following this would be recommended.

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