Diabetic with RUQ Abdominal Pain - Clinical Patient Case of the Week
This abdominopelvic disorders case comes from our MyEMCert Review and CME course (Abdominopelvic Module), part of Med-Challenger's library of board exam review and CME question banks.
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Try this case and test your knowledge of abdominopelvic disorders.
A 67-year-old man with poorly controlled, insulin-dependent diabetes presents with 3 days of fever, nausea, and abdominal pain. He reports the pain as constant and localized in the right upper quadrant.
Vital signs are: temperature 38.9° C (102 °F), heart rate 110 beats/minute, blood pressure 110/70 mm Hg, respiratory rate 22/minute, and oxygen saturation 95% on room air. His abdomen is soft, but tender to palpation in the right upper quadrant, with a positive Murphy sign.
Laboratory results are notable for a white blood cell count of 22,000/µL and a blood glucose level of 320 mg/dL.
Computed tomography of the abdomen is obtained, which is notable for distension of the gallbladder, indicating gallbladder wall thickening, intramural air, and stranding (see Figure).
Figure 1.
Question:
What is a true statement regarding this patient's diagnosis?
Answer Options:
This case, like the majority of cases, is due to gallstones.
It carries a high risk of gallbladder perforation.
The Murphy sign is always present.
A history of diabetes is noncontributory.
See the Answer:
The correct answer is:
It carries a high risk of gallbladder perforation.
Educational Objective:
Define the clinical significance of emphysematous cholecystitis.
Key Point:
Emphysematous cholecystitis occurs predominantly in patients with diabetes, often in the absence of gallstones. Emphysematous cholecystitis is associated with a high risk of gallbladder gangrene and perforation and usually requires urgent cholecystectomy.
Explanation:
Emphysematous cholecystitis is an uncommon, but highly morbid, form of acute cholecystitis that occurs most commonly in men with diabetes.
It presumably occurs when ischemia permits gas-forming bacteria to invade the gallbladder wall.
Although gallstones may be present in emphysematous cholecystitis, 50% of cases are acalculous, suggesting a pathophysiologic mechanism that is primarily ischemic, rather than mechanically obstructive.
The clinical presentation is similar to that of acute cholecystitis; however, in patients with diabetes who have neuropathy, the Murphy sign may be absent, which may be misleading.
The hallmark imaging finding in emphysematous cholecystitis is air within the gallbladder wall.
As the diagnosis carries a high risk for gallbladder gangrene and perforation, treatment is typically broad-spectrum antibiotics and urgent cholecystectomy (usually open).
References:
Haines L, Oyama LC. Disorders of the liver and biliary tract. In: Walls R, et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018:1083-1103.
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