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CASE REPORTS

EMPHYSEMATOUS CHOLECYSTITIS
JA Gandhi, AA Deshpande, JV Hardikar

Emphysematous cholecystitis is an uncommon variant of cholecystitis, incidence of 1%. It is characterized by the presence of gas in the gallbladder wall, presumably consequent to the invasion of the mucosa by gas-producing organisms (e.g. E. coli, Klebsiella sp, and Clostridium perfringens).
INTRODUCTION
Emphysematous cholecystitis is an unusual presentation of acute cholecystitis. We report two diabetic patients treated by cholecystectomy.
CASE 1

A 40 year old diabetic lady presented with history of pain in right upper abdomen, fever and jaundice since 3-4 days. On examination she has tachycardia with tenderness in the right hypochrondrium and absent bowel sounds. Plain abdominal X-ray showed the presence of distended gallbladder with pericholecystic fluid collection. Computed tomography scan of the abdomen showed a distended gallbladder with presence of gas around the gallbladder (Fig. 1).

On exploration the posterior wall of the gallbladder was gangrenous and sloughed out with presence of stones in the gallbladder and presence of turbid pericholecystic fluid. A complete cholecystectomy could be performed safely. Patient had an uneventful recovery and was discharged on 10th postoperative day.
 
Case 2
A 60 year old diabetic lady presented with generalized pain in abdomen and fever since 3 days. Patient had tachycardia with generalized guarding and rigidity on per abdominal examination. Abdominal X-ray showed presence of dilated small bowel loops. Ultrasound examination showed presence of distended gallbladder with a communicating abscess cavity in the right lobe of the liver. Computed tomography (CT) scan of the abdomen was suggestive of an intrahepatic rupture of the gallbladder with presence of gas in the abscess cavity and gallstones lying in the abscess cavity. On surgical exploration, after dissection there was evidence of an intrahepatic rupture of the gallbladder with sloughed off wall, and presence of pus and gallstones in the abscess cavity. Complete cholecystectomy could be performed, and the abscess cavity was drained with portex drain 32F after a good lavage was given.

Post operatively patient had a stormy course due to diabetes and metabolic problems. There was no evidence of a biliary fistula. The pus examination showed the growth of E Coli, which responded well to antibiotics.
 
DISCUSSION
Emphysematous cholecystitis (EC) is a rare but life-threatening complication of acute cholecystitis characterized by early gangrene and perforation of the gallbladder, and an early diagnosis is required to prevent delay in patient management.1 Infection is caused by gas-producing organism (C perfringens, E coli and B fragilis). The morbidity and mortality rate are 15%.2 The immediate treatment for this condition is cholecystectomy, however percutaneous gallbladder drainage is reported in cases where the general condition of the patient is not fit for surgery.3 Emphysematous cholecystitis is also known to cause a rare complication of intrahepatic perforation with formation of abscess. The diagnosis is based on ultrasound and CT scan of the abdomen showing the presence of gas around the gallbladder and if perforated intrahepatic abscess formation with gas in the cavity. The treatment advised is emergency cholecystectomy with the intrahepatic abscess drainage.4,5
 
ACKNOWLEDGEMENT
We would like to acknowledge our Dean Madam
 
REFERENCES
1.
Garcia TL, Rodriguez JA, Fernandez S, Garcia ML. Acute Emphysematous Cholecystitis : Report of 20 cases. Hepatogastroenterology 1999; 46 (29) : 2144-8.
2.
Madrinan M, Fraguela J, Acea B, Taboada L. Emphysematous Cholecystitis. Diagnosis, clinical course, and treatment. Rev Esp Enfem Dig 1999; 91 (12) : 853-6.
3.
Slot WB, Ooms HW, Vander SD, Puylaert JB. Percutaneous gallbladder drainage in emphysematous cholecystitis. Neth J Med 1995; 46 (2) : 86-9.
4.
Peer A, Witz E, Manor H, Strauss S. Intrahepatic abscess due to gallbladder perforation. Abdominal Imaging 1995; 20 (5) : 452-5.
5.
Matsura T, Kato Y, Murakami R, Watanbe M. A case of gas-containing liver abscess associated with emphysematous change in the gallbladder. Hiroshima J Med Sci 1995; 44 (1) : 7-11.
 
ROTAVIRUS IN THE BLOOD-ANOTHER TURN OF THE WHEEL

Roravirus has been known in veterinary circles as an important cause of infantile diarrhoea since the 1950s. Rotavirus persists throughout the world as the main cause of paediatric diarrhoea.

Many infants with rotavirus are feverish and present with symptoms of upper respiratory infection.

In the paper by Blutt and colleagues, assay of the quantity of rotavirus antigen in stools and sera from infected children by ELISA gave similar results.

It remains to be seen whether the finding that rotavirus may be a systemic infection becomes important for vaccine development.

David C A Candy The Lancet 2003; 362 : 1429


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