IMAGES IN SURGERY Emphysematous Cholecystitis: Rare Scenario Revisited Mohan Venkatesh Pulle 1 & Tarun Mittal 1 & Ashish Dey 1 & Vinod K. Malik 1 Received: 14 November 2017 /Accepted: 29 November 2018 # Association of Surgeons of India 2018 Abstract Emphysematous cholecystitis (EC) is a rare form of acute cholecystitis caused by gas-forming organisms. This entity is charac- terized radiologically by presence of air within the lumen or in the wall and carries a high morbidity and mortality. The following article pictorially exemplifies this uncommon presentation managed by laparoscopy. Keywords Emphysematous . Cholecystitis . Laparoscopy . Cholecystectomy A 56-year-old gentleman, a known diabetic for 7 years, presented with right upper abdominal pain, high-grade fe- ver, and jaundice for 1 week. On examination, he was febrile and had tachycardia with hypotension. Abdominal examination revealed severe tenderness in the right hypochondrium, and investigations revealed mild leukocy- tosis (TLC—12.4/c.mm), elevated serum creatinine (2.34 mg/dl), total bilirubin (4.3 mg/dl), direct bilirubin (3.0 mg/dl), and liver enzymes (five to six times the nor- mal). He was initially managed with supportive therapy including IV antibiotics and ionotropic support. Abdominal radiography showed the gallbladder wall was containing gas and CT abdomen was suggestive of distended gallbladder with intramural gas extending into pericolic region (Fig. 1). MRCP revealed no CBD obstruc- tion. Diagnosis of emphysematous cholecystitis (EC) with septic shock was made. Subsequently, he underwent diag- nostic laparoscopy where the gallbladder wall including cystic duct was found gangrenous (Fig. 2) with dense pericholecystic adhesions, and cholecystectomy was per- formed. Post-operatively, he had low output bilious dis- charge with resolution of sepsis. Further follow-up was uneventful. Emphysematous cholecystitis more commonly affects elderly diabetics. Ischemic necrosis of the gallbladder wall due to arterial thrombosis is a proposed etiology [ 1]. Clostridium species is the most common organism isolated from culture [2]. This is a more severe form of disease characterized by rapid progression of symptoms and may deteriorate rapidly due to high propensity for gallbladder perforation. Antibiotic therapy and early surgical interven- tion with intensive post-op monitoring are the cornerstones of management. In patients with poor general condition, cholecystostomy is a reasonable alternative. With increas- ing surgeon experience, laparoscopic cholecystectomy can be safely performed as in our case. * Mohan Venkatesh Pulle mohanvenkateshpulle@gmail.com 1 Sir Ganga Ram Hospital, New Delhi, India Indian Journal of Surgery https://doi.org/10.1007/s12262-018-1847-8