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    EMPHYSEMATOUS CHOLECYSTrITS is asomewhat rare inflammatory disease of thegallbladder caused by a gas-producingorganism and characterized by air withinthe gallbladder lumen, frequently with in-filtration of air into its wall and perichole-cystitic tissues. Other names such as acutepneumocholecystitis, cholecystitis emphyse-matosa, pyopneumocholecystitis, and acutegaseous cholecystitis have been given to thisclinical entity. Because of the paucity ofcases reported and the apparent confusionwhich still exists with regard to the correctmethod of management, the authors feeljustified in reporting an additional case withsuccessful treatment.

    Only 21 bona fide cases of cholecystitisemphysematosa have been reported to date.Kirchmayrl in 1925 was the first to drawattention to this condition. He operated ona 64-year-old male who had a gangrenousgallbladder distended with gas. A cholecys-tectomy was performed and the patient re-covered. Culture of the gallbladder fluidrevealed Frankel's bacillus (Cl. perfrin-gens).

    It was Hegner,2 however, in 1931, whofirst recognized the typical roentgen find-ings of this disease. He describes a case ina 62-year-old man who had an area of gasin the region of the gallbladder simulatingthe contour of that organ. There was alsomottling of gas in the pericholecystic area.This patient was treated conservatively atfirst but the gaseous area increased to four

    * Submitted for publication October, 1950.

    times the original size during the next fourdays. Surgical intervention revealed an en-larged gallbladder filled with gas which wasunder enough pressure to push the plungerout of a 20 cc. syringe. A number of smallabscesses were found in its wall. The gall-bladder was drained and the patient didwell until the fourth postoperative day,when he died of a pulmonary embolus.B. welchii was recovered from the gallblad-der area on culture.

    One year later Simon3 described a casein a 32-year-old man who was admitted witha diagnosis of acute cholecystitis. Roentgenexamination revealed gas over a fluid levelwithin the gallbladder plus additional infil-tration of gas into the pericholecystic area.Here too, in spite of the fact that the pa-tient felt better clinically, roentgen raysshowed increasing pericholecystic infiltra-tion. Surgery was performed and when theperitoneum was opened, gas and bile-stained pus escaped from the fundus of agangrenous gallbladder. Calculi were pres-ent. Cholecystectomy was performed andthe patient recovered. No cultures weretaken but smears of the pus showed "sporesand anaerobic type organisms."

    Wybauw,4 in 1936, described a case in a53-year-old woman with symptoms ofcholecystitis who revealed roentgenograph-ically a gas-filled gallbladder with the wallalso outlined by gas. At operation gas wasfound within the gallbladder wall. Thecourse following cholecystectomy was re-markably smooth. Cultures were not taken.



    In 1938, Schmidt5 reported a 38-year-oldmale who had recurring pains in the rightupper quadrant plus the typical gas-filledgallbladder on roentgen ray examination.Cholecystography showed this identicalarea definitely, though faintly, filled withgallbladder dye. Further examinationsafter barium meal and enema definitely ex-cluded gas accumulations in the gastro-in-testinal tract as sources of the reportedshadow. Under a dietary regimen and bedrest the patient improved rapidly so thatsurgical intervention was deemed unnec-essary.

    Del Campo and Otoro,6 in 1940, de-scribed a case of a 74-year-old man whopresented symptoms of acute cholecystitisand whose roentgenograms showed no gasin the biliary tract, but subsequent films onthe fifth hospital day showed the bile ductsto be filled with gas. Even though the pa-tient was a poor surgical risk, operation wasperformed the following day. A diagnosis ofcholecystitis emphysematosa was not madebefore exploration. The gallbladder re-vealed a large amount of gas under pressureand reddish-yellow pus. Cholecystostomywas performed, but the patient died on thefourth postoperative day. Postmortem ex-amination showed a large calculus impactedin the ampulla of Vater and necrotic areascontaining gas in the lungs, heart, kidneysand liver. Clostridium perfringens was re-covered from the gallbladder pus at thetime of operation, but no cultures weretaken at autopsy.

    Ramey and Scott7 (1942) merely men-tion a case of emphysematous cholecystitismade on the basis of a roentgen ray filmwithout dye. No mention was made of thehistory, physical findings, or disposition ofthis case, and for these reasons we are notincluding this patient in the group of bonafide cases.

    McCorkle and Fong8 in 1942 reportedthree cases of gas in the gallbladder. Thefirst patient was a 49-year-old male who had

    intermittent cramping abdominal painwhich localized in the right upper quadrant.Fever and leukocytosis were present. Threedays later a flat plate of the abdomen re-vealed a gas-filled gallbladder, although thesite of this gas in the right upper quadrantwas noted only in retrospect. On explora-tion, a gangrenous gallbladder was drained,but the patient died about 48 hours afteroperation of a fulminating anaerobic gasbacillus infection of the peritoneum and ab-dominal wall.

    The other two cases reported by McCor-kle and Fong presented the typical signs andsymptoms of acute cholecystitis plus a gas-filled gallbladder on roentgen examination.Both films showed gas overlying a fluid levelin the gallbladder. These two patients weretreated conservatively with one therapeuticdose of polyvalent gas gangrene antitoxinand a course of sulfathiazole. The gas in thegallbladder gradually subsided and the pa-tients recovered. The authors concludedthat conservatism is the desirable course tobe pursued in the therapeutic managementof cases in which gas in the gallbladderresults from anaerobic gas-producingorganisms.

    Three cases of emphysematous cholecys-titis treated successfully were reported byStevenson.9 The first patient was a 64-year-old male diabetic, who had been acutely illfor two days with right upper quadrantpain. Roentgenograms were typical of em-physematous cholecystitis. At operation acompletely gangrenous gallbladder withstones, surrounded by a zone of gas, wasfound. A cholecystostomy was performedand the patient made an uneventful re-covery.

    Stevenson's second case was a 63-year-old acutely ill male, who also had the signsand symptoms of acute cholecystitis, but be-cause of the patient's age, obesity, and poorgeneral condition, he was treated sympto-matically. Fever and leukocytosis continuedand a large mass became palpable in the


    Volume 134Number 2


    right upper quadrant. In the meantime, onroentgen ray examination, the gaseous out-line of the gallbladder became more dis-seminated, indicating rupture of that organ.On the eleventh hospital day abdominal ex-ploration was performed. Upon opening theperitoneum a definite hiss of escaping gaswas heard and large quantities of green pusexuded. A ruptured gangrenous gallbladderwith a stone lodged in the neck was re-moved. The patient made an uneventful re-covery. No intensive effort was made toculture anaerobic organisms in either case.

    The third case was a younger man, 52-years of age, who had right upper quadrantpain, nausea, vomiting, fever, and leukocy-tosis. Roentgenograms were typical ofemphysematous cholecystitis. The patient-was treated with roentgen therapy as sug-gested by Kelley and Dowell,10 specific gasgangrene antisera, and sulfathiazole. Thepatient did not improve remarkably untilthe sixth day of treatment, after which heimproved quite rapidly and was dischargedon the twenty-fourth hospital day. Subse-quent films of the gallbladder, after admin-istration of radiopaque dye, showed no evi-dence of concentration of the dye.

    The two cases reported by Heifetz andSenturall (1938) are interesting. Both pa-tients were treated conservatively at first,but due to-a lack of response to this therapy,surgical intervention was deemed necessary.One patient, a 52-year-old male, was admit-ted with a clinical diagnosis of acute chole-cystitis. Admission roentgenograms showedthe gallbladder to be distended with gas andthe wall sharply outlined. The authors de-cided to postpone surgery because they con-sidered that the optimum period for per-forming a cholecystectomy in the acutestage had passed. The patient was givenpolyvalent gas gangrene antitoxin, penicil-lin, sulfadiazine, and a high carbohydrate-high protein diet. At first the patientshowed some signs of improvement, but thetemperature and pulse remained moderately

    elevated. In a few days, however, the tem-perature and pulse became normal althoughthe leukocyte count remained elevated andthe gallbladder palpable. Gradual dailyrises in temperature to 1000 F. were noted.Serial films of the abdomen during this timeshowed increasing gaseous distention of thegallbladder and pericholecystic infiltration.Operation was then performed over a pal-pable right upper quadrant mass and gashissed out of a walled-off abscess cavitywhich included the necrotic fundus of thegallbladder. Cholecystostomy was deemedthe procedure of choice. The patient didwell except for a slight drainage from theincisional site which persisted for a fewdays.

    The second case was a 57-year-oldwhite female, who had acute right upperquadrant pain and vomiting of two days'duration. Marked tenderness, rigidity, andrebound tenderness was noted in the rightupper quadrant and epigastrium. The pa-tient was treated with penici