A Case of Emphysematous Cholecystitis with Portal Venous Gas and Intraperitoneal Free Gas

Abstract

Emphysematous cholecystitis is a severe gallbladder inflammation caused by gas-producing bacteria, that is often characterized by a rapid clinical course. The patient, a woman in her 80s, presented with abdominal pain and was transferred to our hospital with suspected gastrointestinal perforation based on the presence of portal venous gas and intraperitoneal free gas. When she arrived at our hospital, she was in shock, and emergency surgery was scheduled. Preoperatively, the perforation site could not be identified, and a localized abnormal gas image was observed on the subhepatic surface, and perforation through the intestinal membrane or into the retroperitoneum could not be ruled out. Intraoperatively, however, no perforation could be identified in the gastrointestinal tract, retroperitoneum, or mesentery. The gallbladder was dark purple in color and enlarged, with a snow grip sensation. Based on the findings, we diagnosed the patient as having generalized peritonitis due to acute emphysematous cholecystitis with gangrenous changes, and performed cholecystectomy and intraperitoneal lavage and drainage. Upon reviewing the CT scans postoperatively, we realized that the gas image on the subhepatic surface was the gallbladder, and regretted not having made the diagnosis preoperatively. In patients presenting with portal venous gas and intraperitoneal free gas, emphysematous cholecystitis should be considered in the differential diagnosis.