THE CHANGING FACE OF EMPHYSEMATOUS CHOLECYSTITIS

Emphysematous cholecystitis is a variant of acute cholecystitis charac terized by the presence of gas in the gall bladder lumen, wall or peri cholecystic tissues in the absence of an abnormal communication betwee n the biliary system and the gastrointestinal tract. In the past, the diagnosis has relied on the plain abdominal radiograph (AXR), since th ere are no clinical features to separate this condition from simple ac ute cholecystitis. The apparently high mortality and morbidity associa ted with emphysematous cholecystitis has previously emphasized the imp ortance of emergency cholecystectomy. We have reviewed eight cases of emphysematous cholecystitis presenting to this hospital over the last 5 years. The diagnosis was made on AXR in only one of these cases. Ult rasound (US) scans were performed in all eight cases, of which five we re positive and three negative, due to non-visualization of the gall b ladder. In the three negative cases, the diagnosis was made on subsequ ent CT scans. On initial clinical examination, only one of the eight p atients appeared systemically unwell and conservative management was e mployed in five of the patients. The remaining three patients underwen t cholecystectomy within 3-5 days because of continuing signs or sympt oms. It is concluded that the AXR is relatively insensitive in the dia gnosis of emphysematous cholecystitis. As a result of the regular use of US in suspected hepatobiliary disease, emphysematous cholecystitis is being diagnosed with increased frequency, uncovering a broad spectr um of disease ranging from mild to severe. Previously, failure to sepa rate milder cases from simple acute cholecystitis may have been respon sible for reports of unremitting severity and progression requiring em ergency cholecystectomy. Based on clinical assessment, conservative su rgical management is possible in a significant proportion of patients.