Old man gallbladder syndrome: Gangrenous cholecystitis in the unsuspected patient population

• Gangrenous cholecystitis has been seen more commonly in elderly subjects due to their asymptomatic nature, and many present to the emergency room later and had more complications due to delay in care.
• Risk factors for gangrenous cholecystitis include age and WBC, thickened gallbladder wall on ultrasound and lack of mucosal enhancement. On physical exam, lack of Murphy’s sign, secondary to denervation from gangrenous changes can also increase the index of suspicion.
• Presence of gangrenous cholecystitis can also increase patients’ postoperative complications, morbidity and mortality.

IntroductionAcute cholecystitis is a common surgical condition, but not many are aware of the serious complication of gangrenous cholecystitis (GC). Presence of GC increases patients’ postoperative complications, morbidity and mortality. Predictive factors for GC include age >45, male gender, white blood cell count >13,000/mm3 and ultrasound findings of a negative Murphy’s sign.Case presentation(1) GW, 83 male with dull right upper quadrant pain and a negative Murphy’s sign with further imaging showing a thickened septated gallbladder suggestive of GC. Patient’s surgery was difficult and he received a cholecystostomy tube for drainage. (2) PH, 75 male with minimal right upper quadrant pain, equivocal ultrasound with a negative Murphy’s sign and computer tomography (CT) showing acute cholecystitis. Patient was taken to the operating room for cholecystectomy, with pathology consistent with gangrenous cholecystitis.DiscussionMultiple laboratory findings and imaging patterns have been found to be highly predictive of GC. Along with age and WBC, thickened gallbladder wall and lack of mucosal enhancement have been predictive of GC. On physical examination, lack of Murphy’s sign secondary to denervation from gangrenous changes also increases the index of suspicion for GC.ConclusionGC is a serious complication of acute cholecystitis with increased morbidity and mortality. There should be a high index of suspicion for GC if the above unique physical and laboratory findings are present.