emphysematous cholecystitis ( ec ) is an uncommon variant of acute cholecystitis , which is caused by secondary infection of the gallbladder wall with gas - forming organisms [ 15 ] .
the mortality rate of ec is as high as 25% because of its high complication rate [ 2 , 5 ] due to gangrene , gallbladder perforation , pericholecystic abscess and bile peritonitis .
emergency surgical intervention is necessary for ec treatment for which open cholecystectomy has traditionally been performed [ 1 , 35 ] . here
a 78-year - old male was admitted to our hospital for an investigation of vertigo .
after admission , he developed fever and abdominal distention . a chest x - ray in the up - right position and abdominal computed tomography ( ct )
the chest x - ray showed the presence of gas within the gallbladder and in its wall ( fig .  1 ) .
the ct scan revealed emphysematous changes in the gallbladder wall and air within the gallbladder ( fig . 
the patient was referred to the department of surgery and emergent surgery was performed . 

figure  1:up - right chest x - ray demonstrating air in the gallbladder ( arrow ) and in its wall ( arrowheads ) . 

figure  2:(a  and b ) abdominal computed tomographic scans of axial and coronal views revealing emphysematous changes in the gallbladder wall and air in the gallbladder .
up - right chest x - ray demonstrating air in the gallbladder ( arrow ) and in its wall ( arrowheads ) .
( a  and b ) abdominal computed tomographic scans of axial and coronal views revealing emphysematous changes in the gallbladder wall and air in the gallbladder . based on the hemodynamically stable status of the patient , we selected a laparoscopic approach .
exploration of the abdominal cavity revealed gangrene and necrosis of the gallbladder . to facilitate the resection , we initially punctured the gallbladder using a percutaneous needle to extract bile .
although there was significant adhesion , we were able to safely dissect the calot 's triangle and detected a cystic duct and artery .
his postoperative course was uneventful . a bile culture obtained during surgery revealed clostridium perfringens , enterobacter cloacae and enterococcus faecalis as the causative organisms .
ec is an uncommon variant of acute cholecystitis characterized by potentially high mortality and morbidity because of a high incidence of gangrene or perforation .
garcia et al .   reviewed 20 cases of ec and reported that the mortality rate was as high as 25% and the morbidity rate as high as 50% .
emergent surgical intervention for ec is indicated with cholecystectomy as the definitive treatment , although percutaneous cholecystostomy for critically ill patients presents another option [ 1 , 4 , 5 ] .
bouras et al .   reported that the laparoscopic approach for ec can be considered a safe procedure .
owing to the advances of laparoscopic surgery , it has allowed to perform emergency cholecystectomy .
our patient was hemodynamically stable ; therefore , we selected the laparoscopic approach , which was successfully and safely completed .
the causative organisms of ec include c. perfringens , escherichia coli and species of the genera staphylococcus , streptococcus , pseudomonas and klebsiella [ 15 ] .
ec is associated with diabetes mellitus and primarily affects males , as in the present case .
the symptoms of ec are almost the same as those of acute cholecystitis , including right upper quadrant pain , nausea , vomiting and low - grade fever [ 2 , 4 ] .
a prompt diagnosis of ec is essential and plain abdominal x - rays or ultrasound can be diagnostically useful with a sensitivity of up to 95% .
however , contrast - enhanced abdominal ct scans may offer more information . in our patient ,
a chest x - ray in the up - right position detected air in the gallbladder wall and an abdominal ct revealed typical presentation of ec .
emergency intervention is indicated and the laparoscopic approach can be considered a safe and effective method in hemodynamically stable patients .
 emphysematous cholecystitis ( ec ) is an uncommon variant of acute cholecystitis , which is caused by secondary infection of the gallbladder wall with gas - forming organisms . 
 the mortality rate of ec is still as high as 25% . 
 emergency surgical intervention is indicated . 
 open cholecystectomy has been traditionally accepted as a standard treatment for ec . 
 we present a case of ec successfully treated by laparoscopic surgery . 
 laparoscopic cholecystectomy for ec is considered to be safe and effective when indicated . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONFLICTS OF INTEREST