What is Clostridial Cholecystitis?
Emphysematous cholecystitis is a severe, quick-acting form of acute cholecystitis, which is different from the cholecystitis caused by gallstones in terms of its causes and who it affects. What makes this variation of cholecystitis stand out is the occurrence of gas in the inside and wall of the gallbladder. It’s also possible to find this gas in the bile ducts or neighboring structures, in addition to the gallbladder wall. Even though emphysematous cholecystitis only makes up about 1% of all acute cholecystitis cases, it has notably higher chances of severe illness and death. People who are most likely to get emphysematous cholecystitis are those suffering from diabetes and those with a weakened immune system.
What Causes Clostridial Cholecystitis?
The first documented case of a severe type of gallbladder inflammation called emphysematous cholecystitis dates back to 1901 by a person named Stoltz. However, this severe form still occurs rarely today, affecting between 1% to 3% of patients who get acute cholecystitis, the regular form of gallbladder inflammation.
This harder-hitting version of gallbladder inflammation tends to be found more in older patients who also have diabetes. It appears to be three times more common in males than females. There also seems to be a link between this condition and periphery artery disease as well as immune system suppression. The death rate for this serious form of gallbladder inflammation is reported to be from 15% to 25%.
About 30% to 75% of patients with this type of gallbladder inflammation have diabetes. On average, patients are diagnosed around the age of 60.
Several types of bacteria have been found in patients with this severe form of gallbladder inflammation. This includes:
- Clostridia
- Klebsiella
- Escherichia coli
- Enterococci
- Anaerobic streptococci (type of bacteria that does not need oxygen to grow)
Risk Factors and Frequency for Clostridial Cholecystitis
Emphysematous cholecystitis is a rare, but potentially life-threatening condition that often develops due to lack of blood supply to the gallbladder. This condition is commonly seen in people who are over the age of 50. Certain groups, such as males with diabetes, tend to have a higher likelihood of developing this condition. Most people who get emphysematous cholecystitis are found to have gallstones, although a larger proportion of cases occur without gallstones compared to those with acute cholecystitis.
- Emphysematous cholecystitis is a dangerous health condition that mainly affects people aged 50 and above.
- The condition is more likely to occur in males with diabetes.
- Most people who develop this condition have gallstones.
- However, it’s worth noting that cases of this condition without gallstones are three times more than those of acute cholecystitis with gallstones.
Signs and Symptoms of Clostridial Cholecystitis
Emphysematous cholecystitis is a serious health condition with symptoms similar to other problems that affect the upper abdomen, such as a liver abscess or a perforated duodenal ulcer. The symptoms commonly show up as pain in the right upper part of the abdomen and fever, often with feelings of nausea or vomiting. But these symptoms might not be very intense, which can lead doctors to miss the seriousness of the condition. This is especially true in patients who have diabetes or kidney failure, where even mild symptoms can quickly decline into a more serious state if treatment isn’t given quickly. If the condition isn’t treated, it can worsen into sepsis and shock, a serious complication where the body’s response to infection causes low blood pressure and may lead to organ damage or failure. If the gallbladder has perforated, or burst, signs of peritonitis (inflammation of a thin tissue that lines the abdomen) may appear. Also, if treatment is delayed, symptoms such as a fast heartbeat, low blood pressure, and complete cardiovascular collapse can occur.
- Pain in the right upper part of the abdomen
- Fever
- Nausea or vomiting
- Fast heartbeat, low blood pressure, and complete cardiovascular collapse (if treatment is delayed)
- Signs of peritonitis (if the gallbladder has burst)
- Potential to rapidly decline, especially in those with diabetes or kidney failure
Testing for Clostridial Cholecystitis
Ultrasonography, which is often used for diagnosing gallstone disease, is quite accurate in spotting gas in the wall of the gallbladder. This gas is a sign of a condition called emphysematous cholecystitis. However, this method isn’t perfect as the clarity of the image can be affected by the air present in the wall or the inside of the gallbladder.
To confirm the presence of emphysematous cholecystitis, doctors typically rely on an abdominal CT scan that has been enhanced with a contrast dye. A regular x-ray can also be used, and this may show air or a mix of air and fluid in the gallbladder.
When looking at a CT scan, doctors will confirm if there’s gas in the gallbladder wall or inside the gallbladder. This scan can also provide detailed information about whether there’s air or liquid in the tissue surrounding the gallbladder, as well as free air in the peritoneum (the lining of your abdomen) or, in rare cases, the retroperitoneum (space behind the abdomen). These signs indicate a serious form of emphysematous cholecystitis. The severity is determined based on these radiological discoveries, starting from detection of air only in the gallbladder’s interior and moving to air in both the gallbladder and tissue around the gallbladder for the most severe stage.
An MRI is another imaging tool that doctors may use, as it can accurately detect the presence of air within the gallbladder wall and signs of tissue death.
Blood tests are also part of the diagnosis process. These tests often show an increase in white blood cells. Liver function tests can come back normal or abnormal, depending on the case. Patients also usually have high blood sugar levels.
Treatment Options for Clostridial Cholecystitis
The best way to manage gallbladder disease is through an emergency procedure known as a cholecystectomy, or gallbladder removal. If the gallbladder isn’t suspected to be gangrenous or perforated, the surgery can be done laparoscopically, which involves smaller incisions.
However, if there’s a high risk of perforation and inflammation within the abdomen, an open-cholecystectomy or open surgery is the better option. This is also the case if there’s air within the abdomen that could suggest a tear in the bowel. Surgeons often opt for open surgery if they anticipate complexities during the operation due to fragile tissues or unusual bodily structures.
During the surgery, evidence of a severely inflamed gallbladder may include the presence of air in the tissue surrounding the gallbladder or a frothy collection detected along certain anatomical landmarks within the abdomen. To prevent injury to the bile duct when the anatomy is hard to discern, surgeons may perform an intraoperative cholangiogram, which is a type of X-ray.
If a patient can’t undergo anesthesia due to their overall health status and there’s no sign of inflammation within the abdomen, they may initially have a less invasive procedure where a radiologist drains the gallbladder. Later on, when the patient’s health improves, surgeons can remove the gallbladder.
What else can Clostridial Cholecystitis be?
- Short-term gallbladder inflammation
- Short-term inflammation of the bile duct
- Short-term inflammation of the pancreas
- Long-term gallbladder inflammation
- Stones lodged in the bile duct
- An abnormal connection between the bile duct and the first part of the small intestine
- An accumulation of pus in the gallbladder
- A rupture or tear in the gallbladder
- Blockage of the bile duct which results in yellowed skin (jaundice)
What to expect with Clostridial Cholecystitis
People suffering from emphysematous cholecystitis could experience severe complications, which include:
- Septic shock, a life-threatening infection that can cause organ failure,
- Cardiovascular collapse, where the heart suddenly can’t pump enough blood,
- Death.
Possible Complications When Diagnosed with Clostridial Cholecystitis
There are some complications that can occur after surgery, which include:
- Injury to the bile duct
- Leakage from the bile duct
- Infection of the surgical wound
- An abscess that develops after the operation
Recovery from Clostridial Cholecystitis
People suffering from emphysematous cholecystitis are usually very sick and ideally should be cared for in the intensive care unit. They often need strong hydration treatments, antibiotics that treat a wide range of bacteria, and help for their circulatory system.