Gangrenous Cholecystitis with Atypical Presentation in an Elderly Diabetic Woman

Abstract

In elderly patients, numerous factors subsidize the diagnostic challenge and high incidence of complications in this specific population, taking gangrenous cholecystitis as a critical example. The aim of this work is to report an unusual case of gangrenous choleystitis in an elderly diabetic women and its atypical clinical presentation. A 79-year-old female patient came to our observation; her medical history showed nausea and vomiting of about 2 hours which rapidly ended with symptomatic therapy, without recurrence, and a 3-week history of intermittent fever associated with productive cough. No abdominal discomfort was declared. Physical examination of the abdomen was negative. Laboratory analysis revealed leukocytosis with the remaining criteria within the normal range. After 2 days, she started with a mildabdominal pain in the epigastric region that rapidly progressed to the right upper quadrant, right flank and right iliac fossa, without nausea, vomiting or fever. Abdominal computer tomography findings revealed thickness of the gall-bladder and important densification of the vascular bed. Acute cholecystitis was diagnosed. The patient was then submitted to a laparoscopic cholecystectomy under general anaesthesia with findings suggestive of gangrenous acute cholecystitis confirmed by histologic examination of the specimen. Delays in diagnosing acute cholecystitis in specific populations, such as elderly diabetics, result in a higher prevalence of morbidity and mortality due to potentially serious complications as gangrenous cholecystitis. Consequently, the diagnosis should be measured and investigated promptly in order to prevent poor outcomes.

Acute Cholecystitis Presenting With Septic Shock as the First Presentation in an Elderly Patient

“…In all previously reported cases of perforated GC, the patients were older (>65) and showed a cholecystitis complication (perforated or gangrenous gallbladder) as the first presentation; however, all of them were stable at presentation [9,[13][14][15]. Conversely, our patient exhibited septic shock as the first presentation.…”

“…This report agrees with other similar case reports that highlight poorly controlled diabetes as a cause of late presentation complicated with cholecystitis and perforated gallbladder. Poorly controlled diabetes may obscure the patient's symptoms [14,15].…”

Occult Perforated Gangrenous Gallbladder Found on Magnetic Resonance Cholangiopancreatography

“…Fever, right upper quadrant pain, and jaundice consistent with Charcot’s triad and a positive Murphy’s sign are the most common presentation of a complicated AC [ 7 ]. However, atypical GC can present without the above findings and instead have minimal right upper quadrant tenderness or even a complete absence of pain [ 8 ].…”

Asymptomatic gangrenous cholecystitis diagnosed using contrast-enhanced ultrasonography in a patient with pancreatic cancer

“…Since this condition leads to life-threatening complications such as perforation, abscess formation, and peritonitis [3] , leading to high mortality [2] , accurate diagnosis and prompt surgical treatment are required. These patients generally present with intense abdominal symptoms such as abdominal pain; however, previous studies have reported that several patients with diabetes mellitus (DM) [ 4 , 5 ] and older patients [6] can develop GC without severe abdominal symptoms.…”