A Case of Ruptured Emphysematous Cholecystitis with Generalized Peritonitis

A 70-year-old man admitted for right back pain and vomiting had mild tenderness and rebound pain in the right upper abdomen. Abdominal radiography and computed tomography (CT) couldnot differentiate the ruptured gallbladder from the dilated transverse colon. Abdominal magnetic resonance imaging (MRI) showed gas and fluid in the ruptured enlarged gallbladder and detected the shrunken transverse colon beneath the dilated gallbladder. He had long taken warfarin potassium for pulmonary embolism and his PT-INR was 8.98. After administration of vitamin K2, we undertook emergency surgery for the ruptured distended gallbladder. Massive old blood and clots filled the abdomen. Several gallbladder stones dropped in the Morison pouch. Klebsiella pneumoniae and Clostridium perfringens were found in the ascites culture. We diagnosed him as having perforated emphysematous cholecystitis which tended to coexist with diabetes mellitus and infection caused by aerobic and anaerobic pathogenes. The gallbladder rupture was possibly caused by wall ischemia due to arterial sclerosis and dilation caused by massive blood and clots in the gallbladder. After surgery, he was controlled with mechanical ventilation in the intensive care unit. No serious event occurred postoperatively except for mild pneumonia.