Rapid and unexpected progression of acute cholecystitis to emphysematous cholecystitis in a non-diabetic patient: a case report and review of the literature

Introduction and importance: Emphysematous cholecystitis is a rare, life-threatening form of acute cholecystitis characterized by gas within the gallbladder wall or lumen. Delayed source control increases the risks of gangrene, perforation, sepsis, and death. Case presentation: A 45-year-old non-diabetic Iranian woman presented with right upper quadrant pain. She was afebrile and hemodynamically stable, without systemic inflammation; ultrasonography suggested uncomplicated acute acalculous cholecystitis. Intravenous antibiotics and supportive measures were initiated as temporary preoperative therapy, while early index-admission cholecystectomy was planned. Before surgery, she deteriorated abruptly after 48 hours. Contrast-enhanced computed tomography (CT) demonstrated intramural and intraluminal gas. Emergency laparoscopic cholecystectomy, converted to open surgery because of severe inflammation, was performed within 4–6 hours of the CT diagnosis. Bile cultures grew Escherichia coli and Clostridium species, and histopathology demonstrated transmural gangrenous necrosis. Recovery was uneventful. Clinical discussion: Initial medical therapy was a bridge to surgery, not definitive non-operative management. Nevertheless, emphysematous gangrene developed within 48 hours, a period usually regarded as early. Published evidence favors early cholecystectomy for operable patients and reserves drainage for those who are unfit for surgery. Conclusion: Initial stability should not provide false reassurance in acute acalculous cholecystitis. Early definitive source control and immediate CT reassessment when deterioration occurs are advisable.