Photo Quiz

Abnormal Radiographic Gas Patterns in the Right Upper Quadrant

Am Fam Physician. 2007 Dec 15;76(12):1853-1854.

A 73-year-old man with a history of type 2 diabetes presented with right upper quadrant abdominal pain and fever. Physical examination revealed that the patient had tenderness in the right upper quadrant and a temperature of 100.4° F (38° C). Laboratory studies showed a white blood cell count of 15,500 cells per mm3 (15.5 × 109 per L), with 87 percent neutrophils; an alkaline phosphatase level of 158 U per L (2.64 μkat per L); and a total serum bilirubin level of 1.7 mg per dL (29 μmol per L). Plain abdominal radiography was performed (Figure 1).

Figure 1.

Plain abdominal radiograph.

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Figure 1.

Plain abdominal radiograph.


Figure 1.

Plain abdominal radiograph.

Question

Based on the patient's history, physical examination, and radiographic findings, which one of the following is the most likely diagnosis?

A. Emphysematous cholecystitis.

B. Emphysematous pyelonephritis.

C. Liver abscess.

D. Pneumobilia.

E. Pneumoperitoneum.

Discussion

The answer is A: emphysematous chole-cystitis. Emphysematous cholecystitis is characterized by gas accumulation in the gallbladder lumen, wall, or pericholecystic tissue, which can be seen in imaging studies. This patient's plain abdominal radiograph shows oval-shaped gas accumulation in the gallbladder lumen and linear gas outlining the wall (Figure 1); computed tomography (CT) confirms these findings (Figure 2).

Figure 2.

Computed tomography scan confirming gas accumulation around the gallbladder.

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Figure 2.

Computed tomography scan confirming gas accumulation around the gallbladder.


Figure 2.

Computed tomography scan confirming gas accumulation around the gallbladder.

Emphysematous cholecystitis is a rare but serious manifestation of acute cholecystitis. It is most common in older men with diabetes and has a 15 percent mortality rate.1 It is caused by proliferation of gas-forming organisms (e.g., Clostridium perfringens, Escherichia coli) after vascular compromise of the gallbladder.

Initially, symptoms of emphysematous cholecystitis are indistinguishable from those of uncomplicated acute cholecystitis: right upper quadrant pain radiating to the back, vomiting, fever, and chills. However, because older patients with diabetes may have few or no localizing symptoms or signs, emphysematous cholecystitis should be considered early in at-risk patients.2,3 Emphysematous cholecystitis requires immediate cholecystectomy and broad-spectrum antibiotic therapy.1,2

A diagnosis of emphysematous cholecystitis can be confirmed with plain radiography, ultrasonography, or CT. Plain radiography may be sufficient but has low sensitivity early in the disease.4 Ultrasound findings suggestive of the condition depend on the amount and location of the gas.5 CT is the most definitive modality when findings on plain radiography or ultrasonography are equivocal.4

Emphysematous pyelonephritis is a severe, necrotizing infection of the renal parenchyma caused by gas formation in the collecting system, renal parenchyma, or perirenal tissues. Signs and symptoms are similar to those of acute pyelonephritis. There may be streaky, mottled gas distribution over the infected renal fossa that is associated with an ileus pattern.

Liver abscesses may be associated with amorphous gas collection in the liver (as many as 20 percent of cases) or basilar atelectasis, right hemidiaphragm elevation, and right pleural effusion (about 50 percent of cases).

Pneumobilia is usually secondary to biliary-enteric fistula (spontaneous or surgical), incompetent sphincter of Oddi, biliary-enteric anastomosis (surgical), or cholangitis caused by gas-forming organisms. Spherical, linear, branching gas accumulation in the liver shown on a plain abdominal radiograph represents gas within the intrahepatic biliary duct system.

Pneumoperitoneum often is caused by perforation of the hollow organs. Supine plain abdominal radiographs may show triangular gas accumulation in Morison's pouch, oblong gas accumulation in the subhepatic space, circular gas accumulation over the liver (between the anterior liver surface and abdominal wall), and parahepatic gas bubbles lateral to the right edge of the liver.

Selected Differential Diagnosis of Abnormal Radiographic Gas Patterns in the Right Upper Quadrant

Condition Characteristics

Emphysematous cholecystitis

Gas accumulation in the gallbladder lumen or pericholecystic tissue and linear gas within the wall

Emphysematous pyelonephritis

Streaky, mottled gas distribution over the infected renal fossa that is associated with an ileus pattern

Liver abscess

Amorphous gas accumulation in the liver is possible; basilar atelectasis, right hemidiaphragm elevation, and right pleural effusion

Pneumobilia

Spherical, linear, branching gas accumulation in the liver

Pneumoperitoneum

Triangular gas accumulation in Morison's pouch, oblong accumulation in the subhepatic space, circular accumulation over the liver, and parahepatic gas bubbles lateral to the right edge of the liver

Selected Differential Diagnosis of Abnormal Radiographic Gas Patterns in the Right Upper Quadrant

View Table

Selected Differential Diagnosis of Abnormal Radiographic Gas Patterns in the Right Upper Quadrant

Condition Characteristics

Emphysematous cholecystitis

Gas accumulation in the gallbladder lumen or pericholecystic tissue and linear gas within the wall

Emphysematous pyelonephritis

Streaky, mottled gas distribution over the infected renal fossa that is associated with an ileus pattern

Liver abscess

Amorphous gas accumulation in the liver is possible; basilar atelectasis, right hemidiaphragm elevation, and right pleural effusion

Pneumobilia

Spherical, linear, branching gas accumulation in the liver

Pneumoperitoneum

Triangular gas accumulation in Morison's pouch, oblong accumulation in the subhepatic space, circular accumulation over the liver, and parahepatic gas bubbles lateral to the right edge of the liver

Address correspondence to Fei-Shih Yang, MD, at liupon.liu@msa.hinet.net. Reprints are not available from the authors.

Author disclosure: Nothing to disclose.

REFERENCES

1. Mentzer RM Jr, Golden GT, Chandler JG, et al. A comparative appraisal of emphysematous cholecystitis. Am J Surg. 1975;129:10–5.

2. Garcia-Sancho Tellez L, Rodriguez-Montes JA, Fernandez de Lis S, et al. Acute emphysematous cholecystitis. Hepatogastroenterology. 1999;46:2144–8.

3. Nemcek AA Jr, Gore RM, Vogelzang RL, et al. The effervescent gall-bladder: a sonographic sign of emphysematous cholecystitis. AJR Am J Roentgenol. 1988;150:575–7.

4. Gill KS, Chapman AH, Weston MJ. The changing face of emphysematous cholecystitis. Br J Radiol. 1997;70:986–91.

5. Konno K, Ishida H, Naganuma H, et al. Emphysematous cholecystitis: sonographic findings. Abdom Imaging. 2002;27:191–5.

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