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      Emphysematous Cholecystitis and Necrotizing Pancreatitis: Unusual Combination of Critical Pathology in a Healthy Young Patient

      case-report
      Author(s): 1 , 2 , 1 , 3 , 4 , 5 ,
      Editor(s): ,
      Publication date (Electronic, pub):
      Publication date (Electronic, collection):
      Journal: Cureus
      Publisher: Cureus
      Keywords: emphysematous cholecystitis, laparoscopic cholecystectomy, necrotizing pancreatitis

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          Abstract

          Emphysematous cholecystitis (EC) is a rare form of severe cholecystitis, more common among old, frail males, with comorbidities like diabetes mellitus and peripheral vascular disease. The coexistence of emphysematous cholecystitis with necrotizing pancreatitis is extremely uncommon and in the literature, though it has been reported, no case was of a young patient like the one we are describing. He was treated with laparoscopic cholecystectomy, and his pancreatitis managed conservatively.

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          Most cited references14

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          Emphysematous infections of the abdomen and pelvis: a pictorial review.

          David E Grayson, Robert Abbott, Angela Levy … (2015)
          Emphysematous (gas-forming) infections of the abdomen and pelvis represent potentially life-threatening conditions that require aggressive medical and often surgical management. The initial clinical manifestation of these entities may be insidious, but rapid progression to sepsis will occur in the absence of early therapeutic intervention. Conventional radiography and ultrasonography are often the initial imaging modalities used to evaluate patients with abdominopelvic complaints. However, when a differential diagnosis remains, or if further localization or confirmation of tentative findings is needed, computed tomography (CT) should be considered the imaging modality of choice. CT is both highly sensitive and specific in the detection of abnormal gas and well suited to reliable depiction of the anatomic location and extent of the gas. Of equal importance may be the capability of CT to help reliably identify benign sources of gas, because treatment (if any) varies dramatically depending on the source. Knowledge of the pathophysiologic characteristics, common predisposing conditions, and typical imaging features associated with gas-forming infections of the gallbladder, stomach, pancreas, and genitourinary system will help make early diagnosis and successful treatment possible. In addition, such knowledge will aid in further diagnostic work-up, surveillance of potential complications, and evaluation of therapeutic response. Copyright RSNA, 2002
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            CT findings in acute gangrenous cholecystitis.

            Henry Rusinek, Gary Bennett, G Krinsky … (2002)
            The purpose of this study was to determine the CT findings in acute gangrenous cholecystitis. Four observers retrospectively reviewed CT scans in 75 patients (23 with acute gangrenous cholecystitis, 25 with acute non-gangrenous cholecystitis, and 27 without cholecystitis). The following findings were evaluated: distention, mural thickening, wall enhancement, irregular wall, wall striation, intraluminal membranes, pericholecystic inflammation, gallstones, pericholecystic fluid, enhancement of liver parenchyma, pericholecystic abscess, and gas in the wall or lumen. Sensitivity and specificity of CT for gangrenous cholecystitis and for each finding were calculated. Two reviewers in consensus measured gallbladder dimension and wall thickness. Logistic regression models were used to predict gangrenous versus non-gangrenous cholecystitis. Sensitivity, specificity, and accuracy of CT for acute cholecystitis were 91.7%, 99.1%, and 94.3%, respectively, and for acute gangrenous cholecystitis were 29.3%, 96.0%, and 64.1%, respectively. Findings with the highest specificity for gangrenous cholecystitis were gas in the wall or lumen (100%), intraluminal membranes (99.5%), irregular or absent wall (97.6%), and abscess (96.6%). The difference between the mean gallbladder wall thickness and the short-axis dimension for the two groups with cholecystitis was statistically significant. In three patients with gangrenous cholecystitis, no mural enhancement was seen. Pericholecystic fluid also achieved statistical significance for the diagnosis of gangrene. Multivariate logistic regression analysis showed that the overall accuracy of CT for gangrenous cholecystitis was 86.7%. CT findings most specific for acute gangrenous cholecystitis are gas in the wall or lumen, intraluminal membranes, irregular wall, and pericholecystic abscess. Gangrenous cholecystitis is associated with a lack of mural enhancement, pericholecystic fluid, and a greater degree of gallbladder distention and wall thickening.
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              A comparative appraisal of emphysematous cholecystitis.

              R M Mentzer, G T Golden, J G Chandler … (1975)
              There is ample evidence from this retrospective comparison to indicate that emphysematous cholecystitis does merit clinical distinction apart from acute cholecystitis. It is an acute infection of the gallbladder caused by a specific group of bacteria that may be aided by some aspect of local ischemia. Cholelithiasis does not seem to be a major factor in the pathogenesis of emphysematous cholecystitis, and this, in association with some dependence upon ischemia, may account for the predominance of this disease in males rather than females. Gangrene is a common feature of the pathologic process, and thus it is not surprising that the diagnosis of emphysematous cholecystitis implies a risk of gallbladder perforation that is five times that expected from ordinary acute cholecystitis. The key to identifying this disease is the plain abdominal roentgenogram which in most instances will make the diagnosis and provide an impetus for early operative intervention.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Cureus
                Journal ID (iso-abbrev): Cureus
                Journal ID (issn): 2168-8184
                Title: Cureus
                Publisher: Cureus (Palo Alto (CA) )
                ISSN (Electronic): 2168-8184
                Publication date (Electronic, pub): 18 August 2020
                Publication date (Electronic, collection): August 2020
                Volume: 12
                Issue: 8
                Electronic Location Identifier: e9843
                Affiliations
                [1 ] General Surgery, Hamad Medical Corporation, Doha, QAT
                [2 ] Acute Care Surgery, Hamad Medical Corporation, Doha, QAT
                [3 ] Radiology, Hamad General Hospital, Doha, QAT
                [4 ] Surgery, Weill Cornell Medical School, Doha, QAT
                [5 ] Acute Care Surgery, Hamad General Hospital, Doha, QAT
                Author notes
                Article
                DOI: 10.7759/cureus.9843
                PMC ID: 7497293
                SO-VID: e650c5cb-9231-4ba7-97f8-8ff0b66bb8e9
                Copyright © Copyright © 2020, Abu Amr et al.
                License:

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                Date received : 4 August 2020
                Date accepted : 18 August 2020
                Categories
                Subject: General Surgery

                Keywords: emphysematous cholecystitis,laparoscopic cholecystectomy,necrotizing pancreatitis
                Data availability:
                Keywords: emphysematous cholecystitis, laparoscopic cholecystectomy, necrotizing pancreatitis

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