Colecistita emfizematoasã. Retrospectivã a 5 cazuri si complicatiile musculoscheletice

Introduction
Emphysematous cholecystitis is an acute infection of the gallbladder wall caused by gas-forming organisms. Emphysematous cholecystitis is not a common disorder. Reports in the literature indicate that this medical entity develops in approximately 1% of all cases of acute cholecystitis.
Up to 1990, 220 cases had been reported, whereas in 1999 approximately 260 cases where known (1, 2).
In this paper, apart from the 5 cases of emphysematous cholecystitis, we describe the exceedingly rare case of a metastatic gas gangrene to the lower extremity developed in a patient in association with acute emphysematous cholecystitis and the develop of septic knee arthritis in another patient, three months after emphysematous cholecystitis.

Patients and Methods
During the last fifteen years, five cases of emphysematous cholecystitis were treated in our Departments. The age of the patients ranged from 55 to 78 years and there were 4 males and 1 female patients. All patients but one, had diabetes mellitus, and two patients had known cholelithiasis.
We reviewed the clinical records of these patients with acute emphysematous cholecystitis, analyzing age, sex, predisposing factors, symptoms, laboratory tests, X-rays, ultrasounds, operative and bile culture findings, morbidity and mortality.

Results
Clinical features included pain in the right hypochondrioum and fever (range 38.2-39.2) in all cases. Vomiting was evidence in four cases out five. Only in one patient these symptoms were appeared soon after a fatty meal. All patients admitted urgently to our department except one who was transferred to the Surgical Department from the Internal Medicine ward, where was hospitalized for intractable diabetes mellitus and renal insufficiency.
Plain abdominal X-rays showed air accumulation in gallbladder in four cases (80%).
Echo confirmed the diagnosis in same cases. On the other hand CT-scan demonstrated pathologic findings in all cases. WBC levels were elevated over 14000/mm3 in all patients.
Emergency open cholocystectomy was performed in three cases and percutaneous trans gallbladder drainage was decided in two patients becouse the general condition of them was poor and lithiasis was not present. Only in one case gangrenous gallbladder was found. Escherichia Coli was the most common microrganism which revealed by bile culture.
Features of the five patients are shown at tabelul 1.
The postoperative course was uncomplicated for three patients. Unfortunately there was one early and one late muscolosceletal complication.
A 78-year-old with acute emphysematous cholecystitis underwent percutaneous trans gallbladder drainage. Eight hours later, the patient developed sudden pain in the right leg. On physical examination skin redness, swelling and crepitation were revealed. The plain radiogram of the limb showed air accumulation in the intramuscular space of the leg (Fig. 1). She was diagnosed as having gas gangrene and incisures of the skin were performed and cultures of tissues samples were taken. Despite of our intensive medical care, the patient's condition was deteriorated and amputation below knee was performed. However, the patient developed septicemia, complicated by disseminated intravascular coagulopathy and died 36 hours later. All cultures from the blood, bile and tissue samples of the leg revealed the same organism, i.e. Clostridium perfringens.
Besides an 70 years old man was admitted to our emergency department with emphysematous cholecystitis without lithiasis. His medical history included cardiac failure. The patient underwent percutaneous trans gallbladder drainage.
Three months later the same patient admitted to our emergency department with increasing right knee pain and fever of 38.2ºC. The knee was flexed at 15º,warmth, redness and any attempt to move the joint was painful.
The diagnosis was knee septic arthritis and the patient underwent arthroscopic drainage with excellent results (Fig. 2).

Discussion
Emphysematous cholecystitis is a virulent form of acute cholecystitis accompanied by gas formation. The disease has been first described as an intraoperative finding in 1907 by Pende (3). The pathology is also cited as "gaseous cholecystitis", "pyopneumonocholecystitis" or "pneumo-cholecystitis", but the term emphysematous cholecystitis has prevailed (4).
It is a rare entity since it is found in the 1-4% of the cases of acute cholecystitis (5). Emphysematous cholecystitis is a life-threatening disease with morbidity and mortality rates much higher than those for other types of acute cholecystitis. In emphysematous cholecystitis air bubbles accumulate in the gallbladder or penetrate into the pericholecystic area, or even enter the bile ducts to produce pneumobilia after anaerobic infection (6, 7). The most acceptive causative factor for the genesis of such gaseous accumulation is the obstruction of the cystic duct, followed by acute cholecystitis due to gas-producing organisms, such as Escherichia coli, Clostridium Welchii, Clostridium Perfringens, Enterobacter etc.
Diabetes mellitus is considered as a predisposing factor (2). Furthermore, males are more frequently affected (8, 2).
Preoperative diagnosis can be made by plain rentgeno-gram of the abdomen, ultrasonography and computed tomo-graphy (9-13).
The presence of gas in imaging studies is characteristic for the diagnosis of emphysematous cholecystitis. Usually gas is not revealed during the first 24 hours. After that time, x-rays may show distention of the gallbladder with gas accumulation within it. Following that, 72 hours after the onset of symptoms, gas penetrates into the submucosa and pericholecystic tissues, appearing as numerous radiolucent strations. After the first 72 hour, our bubbles may enter the bile ducts (6, 14, 15).
Gallbladder cultures in cases of emphysematous cholecystitis have been reported to yield positive growths in 95% of the cases. In 50% of these cases clostridia are isolated with the most commonly met Clostridium Welchii, associated many times with Escherichia coli, which is also found less often (16).
Other potential gas-formers are anaerobic streptococci (17). It is also well known though that clostridia create easier ischemia and gangrene of the tissues (16,17).
The signs and symptoms of emphysematous cholecystitis are essentially the same as those of ordinary acute cholecystitis; pain is sharp and usually well localized in the right upper quadrant of the abdomen and tenderness and muscle guarding over the right abdomen are the rule. About one fourth of patients exhibit jaundice (16).
Fever is common, with mean temperature of 38,3ºC and around 80% of patients less than 38,8ºC. Leukocytosis is fairly constant with counts of the white blood cells ranging from 14.000 to 16.000/mm3.
The overall mortality rate is approximately 25%, while in acute cholecystitis it is 4,1% (18). Gangrene is 30 times more common and perforation four times higher than in ordinary acute cholecystitis.
A rare complication of emphysematous cholecystitis is the so-called nontraumatic gas gangrene to the lower extremities. It is well known that gas gangrene of the lower extremities is frequently associated with subcutaneous emphysema due to trauma. Furthermore, intraabdominal diseases is a rare course of subcutaneous emphysema either as a result of an enteric fistula, or due to hematogeneously spreading of gas-forming organisms by an intraabdominal focus, as in our patient was most likely occurred.
In support of this aspect was the fact that all cultures from the bile, blood and tissue samples from the leg revealed the same microorganism (clostridium perfringens).
In conclusion, we can say that emphysematous cholecystitis is a rare variant of acute cholecystitis that can be diagnosed radiologically. The treat of imminent perforation of the gallbladder, which probably has gangrenous changes, makes prompt diagnosis and surgical treatment imperative. The administration of broad-spectrum antibiotics and cholocystectomy open of laparoscopic is the treatment of choice in cases of emphysematous cholecystitis. In the elderly and in high risk patients, especially without cholelithiasis, percutaneous trans gallbladder drainage could be performed. Especially in these cases and when diabetes mellitous is a predisposing factor we must be aware of early or late unusual complications such as septic arthritis and gas gangrene of lower extremities.

References
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