Unusual Presentation of a Gangrenous Cholecystitis that
Mimics a Bowel Perforation
Occhionorelli S1, Stano R2, Bonazza S1, Morganti L1*,
Andreotti D1, Cappellari L2 and VasquezG2
1Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Via Luigi Borsari 46-Ferrara, Italy
2Department of Surgery-Emergency Surgery Service, Via A. Moro 8, 44100, Ferrara ER, Italy
Morganti Lucia, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Via Luigi Borsari
46-Ferrara, Italy, E-mail:
Received: March 14, 2014; Accepted: August 07, 2014; Published: September 26, 2014
Occhionorelli S, Stano R, Bonazza S, Morganti L, Andreotti D, et al. (2014) Unusual Presentation of a Gangrenous Cholecystitis
that Mimics a Bowel Perforation. A Case Report. SOJ Surgery 1(2), 3. DOI: http://dx.doi.org/10.15226/2376-4570/1/2/00108
We report the case of a diabetic 49-year-old man affected by
phlegmonous cholecystitis with an unusual radiological presentation
mimicking a bowel perforation. Actually, abdomen X-ray showed free
intraperitoneal air spots (dark crescent beneath the diaphragm)
in the upright positions. We have not found any similar cases in
the published literature, except for a case report about an unusual
presentation of an emphysematous cholecystitis. The clinical
practitioner has to pay attention not to fall into a fixation error during
US:Ultrasound; BMI: Body Mass Index; ER: Emergency Room;
PT: Prothrombin Time; INR: International Normalized Ratio;
APTT: Activated Partial Thromboplastin Time; CT: Computed
Tomography; PDS: Polydioxanone(suture); UI: International Unit
Gangrenous cholecystitis is a severe gallbladder infection,
which occurs approximately in 1% of acute cholecystitis. This
condition is characterized by the presence of gas in the gallbladder
lumen, as well as in its wall or nearby tissues, without abnormal
communication among the digestive and biliary ducts . This
infection is caused by gas-producing organisms (Escherichia coli,
Clostridium perfringens, Bacteroides fragilis) and complications
include hepatic abscess formation, biliary sepsis and hepatorenal
failure . Abdominal X-ray and abdominal Ultra Sound (US)
scan  are the first modality to detect gallbladder infection and
might demonstrate the presence of air inside the gallbladder wall
or lumen, in nearby tissues or in the biliary ducts.
Additionally, an abdominal Computed Tomography (CT)
scan might be useful to identify possible gallstones in biliary
ducts, irregularity or thickening of the gallbladder wall, presence
of intraluminal or mural air, presence of pericholecystic fluid,
extension of the inflammatory process to hepatic parenchyma
[4,5]. Surgical intervention is usually the procedure of choice
in phlegmonous and gangrenous cholecystitis (partial or total
cholecystectomy). A less invasive approach (i.e. percutaneous transhepatic gallbladder drainage under US guidance) can
be effective before a phlegmonous cholecystitis becomes
A male patient aged 49 years, obese (Body Mass Index
(BMI)= 52.24), affected by Type II diabetes was presented
to Emergency Room (ER) with a complaint of strong upper
abdominal quadrants pain, without other associated symptoms.
Approximately 7 days before, he had a similar pain associated
with high fever and vomiting, which withdrew with antibiotic
treatment (moxifloxacin). On physical examination, the abdomen
was diffusely tender, despite treatment with opioids. Moreover,
the patient showed blood hypertension (200/100 mm Hg) and
tachycardia. Laboratory investigations revealed leucocytosis
(white blood cells 17.58×103/microL, neutrophil 12.36×103/
microL), mild alteration of coagulation (Prothrombin Time
(PT) 1.37 International Normalized Ratio (INR) , fibrinogen 946
mg/dl, Activated Partial Thromboplastin Time (APTT) ratio
1.33), hyperglycemia 232 mg/dl. In addition, he showed light
hyperbilirubinemia (total bilirubin 1.77 mg/dl, direct bilirubin
1.30 mg/dl), mild electrolyte disturbance (Na 134 mEq/L, Cl 96
mEq/L), hyperamylasemia 180 U/l and the level of C-reactive
protein was 16.47 mg/dl. Abdominal X-ray revealed a dark
crescent beneath the diaphragm, as a bowel/gastric perforation
(Figure 1). Because the clinical condition of the patient was
quickly worsening and diagnosis seemed fairly clear, a CT scan
was not performed and the patient was brought to the operating
room, without further investigations.
An exploratory laparotomy was performed. The operation
showed diffuse peritonitis and presence of purulent liquid in all
the abdominal recess, without macroscopic intestinal or gastric
perforations. The gallbladder had no signs of perforation but
was affected by an advance inflammatory process, which led to
emphysema with gangrene.Moreover, the gallbladder appeared
non detachable from the duodenum and the liver. An anterograde
subtotal cholecystectomy with infundibular closure through
running Polydioxanone Suture ((PDS) 3/0) was performed,
after gallstones were removed. A more careful exploration of
the abdominal organs and the test with methylene blue through
In literature, there are few other cases of emphysematous/
gangrenous cholecystitis presented with pneumoperitoneum
[6,7]. These patients have some common features: diabetes,
upper quadrant abdominal pain (right more than left, and
not necessarily with fever), leucocytosis, lithiasic gallbladder
and specific bacterial isolation (E. coli, C. perfringens or B.
fragilis). Anaerobic organisms grow easily in gallbladder with
vascular insufficiency of the wall and alkaline bile, as occurs in
cholecystitis. The excessive distension of the gallbladder wall
can result into a leakage of gas through the intact mucosa, with
the gas spreading into the perimuscular layers and collecting
under the serosa and into the peritoneal cavity . Gangrenous
cholecystitis is a life-threatening condition, which can require
one- or two-step early surgical intervention . Fixation errors
could easily happen. Free intraperitoneal gas detected by
radiological investigations, could be a suspected cause, but not
a conclusive diagnosis for organ perforation. If the patient is
stable and has plenty of comorbidity, it is preferable to proceed
with further radiological investigations (i.e. abdominal CT scan)
in order to make a more careful differential diagnosis .
Actually, Advanced gallbladder inflammations and infections
in some critical patients, can be managed effectively by a twostep
approach; wherein a minimally invasive ultrasound guided
drainage, is followed by cholecystectomy [11,12]. Because of
a lack of evidence from randomized trials [13,14], it remains
unclear if acute cholecystitis treatment, would benefit more from
the routine use of cholecystostomy as a unique treatment, or
using it as a bridge to laparoscopic or laparotomic surgery. There
is a need for a clear diagnosis and a clinical stabilization [11,12]
to allow more in-depth diagnostic work. In our case, this was
not possible for two reasons: (a) poor conditions of the patient and (b) the diagnostics addressed to a perforation of a hollow
organ. In addition, at the time of the intervention, the patient
showed a gangrenous cholecystitis case, with no indications for
Gangrenous cholecystitis represents a life-threatening
condition, which requires a surgical procedure in emergency
setting. A large gas production is unusual but it might occur:
this can lead to a wrong diagnosis but the clinical conditions
of the patient, however, require an urgent surgical procedure.
Regarding the possibility of treating acute cholecystitis by
ultrasound-guided drainage, there is an ongoing debate that
must define which cases must be treated and in which way.
Figure 1: Dark crescent beneath the diaphragm.
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