Clinical Image
Is it just another case of acute uncomplicated cholecystitis? A case of emphysematous cholecystitis an uncommon complication and associated image findings
Sinead Culleton1, John Bruzzi2
1MB BCh Bao MRCPI, Department of radiology, Galway University Hospital, Galway, Ireland.
2MB, MRCPI, FFRRCSI, FRCR, Department of radiology, Galway University Hospital, Galway, Ireland.

Article ID: Z01201603CL10098SC

Address correspondence to:
Sinead Culleton
Department of radiology
Galway University Hospital

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Culleton S, Bruzzi J. Is it just another case of acute uncomplicated cholecystitis? A case of emphysematous cholecystitis an uncommon complication and associated image findings. Int J Case Rep Images 2016;7(3):198–200.

Case Report

A 78-year-old male presented to the emergency department with a one-day history of sudden onset, acute and severe right upper quadrant pain. He had no known medical or surgical history. On examination he was Murphy's positive, pyrexic and tachycardic. He was not jaundiced. His inflammatory markers were elevated. Two sets of blood cultures were negative. An admission chest X-ray and plain film of the abdomen were both normal. He was treated as acute cholecystitis.

An abdominal ultrasound was performed. His pain was increasing in severity. This showed a markedly distended gallbladder which contained gallstones and sludge. There was low level posterior shadowing and reverberation artifact ("dirty shadowing") from the gallbladder. These findings are due to air or gas in the gallbladder wall. Also, there were a number of tiny echogenic reflectors, which were foci of gas and appeared to be rising towards the nondependent portion of the gallbladder lumen. This is known as the champagne sign and seen in (Figure 1). It is so called as it is thought to resemble the effervescent bubbles of champagne rising from a glass [1] [2] [3] [4] [5]. It is specific but insensitive for emphysematous cholecystitis and is also an uncommon finding.

Further imaging was required following these ultrasound findings to confirm the diagnosis. A repeat abdominal X-ray, (Figure 2), confirmed the presence of air in the gallbladder and the diagnosis of emphysematous cholecystitis suggested on the abdominal ultrasound. A computed tomography scan of abdomen excluded a perforation of the gallbladder and again showed an emphysematous gallbladder. He went for an emergency cholecystectomy but unfortunately died one day later from sepsis.

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Figure 1: Ultrasound of the gallbladder. Non-shadowing Echogenic foci rising up from the dependent portion of the gallbladder.

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Figure 2: Plain film of the abdomen with air in the gallbladder wall (large arrows).


Emphysematous cholecystitis is a condition which is characterized by the presence of gas in the gallbladder wall. This is typically due to gas forming organisms such as Clostridium welchii or Escherichia coli. Usually, this condition is seen in patients aged 50–70 years. There are a number of ways in which it differs from acute cholecystitis. These are important to recognize as prompt recognition may reduce mortality. Acute cholecystitis is more common in females. However, emphysematous cholecystitis is more commonly seen in males. Emphysematous cholecystitis is also more commonly associated with perforation of the gallbladder or acalculous cholecystitis than acute cholecystitis. It is postulated that vascular compromise of the cystic artery, not only plays a role but may also explain the male predilection [2].

It can be clinically challenging to distinguish acute and emphysematous cholecystitis as patients typically present with similar symptoms including right upper quadrant pain, nausea and pyrexia. These symptoms are often insidious but may rapidly progress to this surgically emergent state, requiring urgent surgical intervention. There are few signs or symptoms can confidently differentiate acute complicated cholecystitis from acute uncomplicated cholecystitis and it is imaging that often makes the diagnosis. Acute cholecystitis is a common frequent presentation to the emergency department but it is important to consider is it just another case of uncomplicated cholecystitis? Or could it be an emphysematous gallbladder.

The typical imaging findings seen on ultrasound and abdominal radiographs have been described above. Additional findings on an abdominal radiograph may include an air-fluid level. However, this will only be observed in those radiographs which are taken with a horizontal beam, and are not seen on supine abdominal X-rays. If an abdominal ultrasound suggests that there is air in the gallbladder wall then further imaging either with a CT of the abdomen or an abdominal X-ray is recommended. A CT scan of the abdomen is considered to be the most sensitive and specific imaging modality for detection of gas within the gallbladder wall or lumen 2. In addition, a CT scan may demonstrate additional important imaging findings such as air outside the gallbladder wall or lumen, pneumoperitoneum, due to perforation of the gallbladder wall. A pericholecystic fluid collection may also be seen, or dense bile contained within a distended gallbladder.

The mortality rate for emphysematous cholecystitis is quoted as approximately 15–25% compared to 2% for uncomplicated cholecystitis. Emphysematous cholecystitis requires early recognition and treatment to prevent not only patient death, but to reduce morbidity and improve patient and surgical outcomes. The definitive treatment is an urgent cholecystectomy. However, many of these patients are often too unwell for immediate surgery and often have a number of comorbidities making then unsuitable surgical candidates and in such patients a percutaneous cholecystostomy may be an alternative treatment option.


It can be difficult to clinically differentiate acute uncomplicated cholecystitis and emphysematous cholecystitis in the early stages of presentation due to a lack of specific clinical findings which can adequately distinguish between these two entities. As emphysematous cholecystitis carries a high mortality rate and imaging can be invaluable in diagnosing complications associated with cholecystitis.

Keywords: Acute cholecystitis, Emphysematous cholecystitis, Champagne sign, Gallbladder, Murphy's positive

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Author Contributions
Sinead Culleton – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
John Bruzzi – Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
Conflict of interest
Authors declare no conflict of interest.
© 2016 Sinead Culleton et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.