Perforated Necrotizing Cholecystitis, Niemeier Type II, With Subcutaneous Abscess in a Frail Elderly Patient: Challenges in Diagnosis and Management

Perforated necrotizing cholecystitis is a life-threatening complication of acute cholecystitis (AC), particularly in frail elderly patients, in whom atypical presentations may delay diagnosis. We report the case of an 89-year-old man with significant cardiovascular, cerebrovascular, and renal comorbidities who presented with abdominal pain, nausea, and a palpable right upper quadrant mass mimicking gallbladder hydrops at presentation. Laboratory findings showed leukocytosis, elevated inflammatory markers, and acute-on-chronic renal dysfunction. Contrast-enhanced CT revealed perforated necrotizing cholecystitis with a large 13 × 3.4 cm loculated pericholecystic abscess. Given the hostile operative field and high surgical risk, the patient underwent open drainage and cholecystostomy. Cultures grew multidrug-resistant Pseudomonas aeruginosa sensitive only to colistin. Despite targeted antimicrobial therapy and intensive care support, the patient developed multi-organ failure and died on postoperative day eight. This case highlights the diagnostic challenges of atypical presentations in elderly patients, emphasizing the importance of early CT imaging, prompt source control, and consideration of multidrug-resistant pathogens. Mortality remains high in the presence of advanced organ dysfunction.