Successful medical management of emphysematous cholecystitis in a patient with acute hepatitis: case report

¹Department of Internal Medicine, Edward Francis Small Teaching Hospital, Banjul, The Gambia, ²School of Medicine and Allied Health Sciences, University of The Gambia, Banjul, The Gambia

^&Corresponding author
Sheikh Omar Bittaye, Department of Internal Medicine, Edward Francis Small Teaching Hospital, Banjul, The Gambia

Introduction    

Emphysematous cholecystitis (EC) is an acute infection of the gallbladder wall caused by gas forming organisms [1]. It is a life-threatening form of acute cholecystitis presenting mainly in male patients aged 50-70 years, and mostly in patients with diabetes mellitus, immunosuppressed and peripheral vascular disease [2]. The mortality rate of EC is as high as 25% because of its high complications [3] such as gangrene, gallbladder perforation, pericholecystic abscess and bile peritonitis [4]. Emergency surgical intervention either open cholecystectomy [1,5] which has traditionally been used or more recently laparoscopic surgery [4] is found necessary for EC treatment.

Patient and observation     

Patient information: we present a 37-year-old female who presented to our clinic with a 2-month history of progressive jaundice. This was associated with generalized body weakness, abdominal pain, fever, vomiting and dark coloured urine. She had no history of pale stools or pruritus. Patient delivered a still birth, 3 months ago at 40 weeks gestations by spontaneous vaginal delivery and has been taking herbal remedies (boiled groundnut husk, boiled pawpaw leaves, palm oil and sorrel) for the above symptoms. She had no significant past medical history, but has a strong belief that injecting jaundice patients worsens their condition.

Clinical findings: on examination, she had jaundice (+) with right hypochondriac tenderness. Vital signs showed a blood pressure of 120/75 mmhg, pulse of 96 bpm and temperature of 35.1°C.

Diagnostic assessment: investigations revealed a positive hepatitis B surface antigen with a viral load of 1507 iu/l, INR of 1.5, random blood sugar of 2.8mmol/l, White blood cell count of 8.4 x 109/l and median fibroscan score of 8.8kpa. She also had a normal renal function test and lipid profile. Liver function test and urinalysis results are shown in the table below (Table 1). Computed tomography scan showed a hypodense image at the head of the pancreas, involving the gallbladder and extending to the common bile duct and portal vein. Abdominal scan showed an echogenic image of the gallbladder with diffuse mural thickening of gallbladder wall. There was also considerable free fluid collection in pouch of Douglas.

Therapeutic interventions: she was put on 50 mls of 50% dextrose and 500mls of 10% dextrose TDS with IV ciprofloxacillin 500 mg BD and metronidazole 500 mg TDS for 24 hrs. Oral ciprofloxacillin 500 mg BD and metronidazole 500 mg TDS were continued for 2 weeks. She was also advised to stop all herbal remedies she was taking.

Follow up and outcome of interventions: on follow up 2 weeks later, patient became much better and had no complaints but still had jaundice (+). Four weeks later the jaundice disappeared, and vital signs were, blood pressure 135/93mmhg, pulse 76bpm, temperature 36.2°C. Liver function test and urinalysis (Table 1) also improved. The patient had regularly been followed up at our clinic for the past 2 years and has not reported or developed any complications.

Patient perspective: patient felt better and was very happy and jokingly suggested spending some time in one of the author's home to help with house chores.

Informed consent: the patient gave informed written consent about the publication of this article

Diagnosis: all the above clinical, laboratory and imaging results confirmed the diagnosis of emphysematous cholecystitis in a patient with acute hepatitis.

Discussion     

To our knowledge, this is the first reported case of EC with acute hepatitis and successfully managed medically in The Gambia. Most cases of EC occur in male patients with age between 50-70 years, and approximately 50% of them have diabetes mellitus and peripheral vascular disease. Vascular compromise of the cystic artery is thought to play a role in the evolution of the emphysematous form of this disease [2]. In addition, gallstones are also found in 40% of EC patients [6]. In our case, our patient did not have typical EC clinical features. She was female and of a younger age. However, our patient delivered a still birth 3 months prior to presentation and has been sick since then.

In general, right upper quadrant abdominal pain, fever, nausea and vomiting are typical symptoms of EC [6]. In this case, the patient had a typical presentation. In addition to these symptoms, our patient also had jaundice, which is not common in these patients. Almost all published cases of EC showed the presence of normal or minimally raised transaminases [7,8]. In this case there were markedly raised transaminases which could have been due to acute hepatitis resulting from hepatitis B virus infection and/or drug induce hepatitis due to the excessive use of the different herbal medications. Another contributing factor could have been the involvement of the pericholecystic tissue. The strong belief that injecting jaundice patients worsens their condition or kills may have also resulted in her presenting late to our clinic, which could have also contributed to the severe progression of the disease. Most patients with EC also have a raised white blood cell count, serum glucose, and total bilirubin [6]. In our patient, the white cell count was normal with a raised bilirubin and decreased blood sugar levels. The raised bilirubin and hypoglycaemia could be explained by the extent of the severity of the disease and also the effect of the hepatitis B and herbal medications on the liver.

The diagnosis of EC is made by finding gas in the lumen and/or wall of the gallbladder, or in the pericholecystic tissue on plain abdominal X-ray, ultrasound or CT scan [6]. Staging of emphysematous cholecystitis with conventional radiography has been described. Stage 1 emphysematous cholecystitis is characterized by gas within the gallbladder lumen, Stage 2 by gas within the gallbladder wall, and stage 3 by gas within the pericholecystic tissues [2]. In our case, both ultrasound and CT scans were used to establish our diagnosis. The patient´s progression was monitored with liver function test and urinalysis. In the treatment of EC, early cholecystectomy (open or laparoscopic intervention) is carried out because of rapid progression of the disease, which may result in complications and finally mortality. Antibiotics that have broad coverage against anaerobes, enteric Gram negative and Gram positive organisms should be initiated immediately [9]. In this case, broad spectrum antibiotics were started immediately, but no emergency cholecystectomy was done. However, broad spectrum antibiotics alone and close monitoring helped in successful treatment of this patient. The patient remained asymptomatic for more than 2 years and has not had any complications.

Conclusion     

We report the first case of EC with acute hepatitis and markedly raised transaminases successfully managed medically in The Gambia. In resource limited countries, where cholecystectomy may not be readily available, early diagnosis and prompt initiation of broad spectrum antibiotics with close monitoring may help treat and prevent complications.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

SOB, ST, SJ and RN conceived the case report and did the data collection and analysis. All authors contributed to the drafting and revision of the manuscript. All authors read and approved the final version of the manuscript.

Table     

Table 1: laboratory investigations at presentation, 2 and 4 weeks

References