Pneumo-cholecystitis is a rare disorder comprising approximately 1% of cases of acute cholecystits. Impaired vascularity with superimposed gas forming bacterial infections leads to pneumo-cholecystitis. Advanced age, diabetes mellitus, impaired immunity, atherosclerosis are predisposing factors.
We managed a case of pneumo-cholecystitis in a jaundiced patient with hepatitis B infection, who presented with pneumoperitoneum. A thirty five year female had pain abdomen localized to right upper quadrant of abdomen for four days. Vague and tender lump (4cm x 7cm) below right subcostal margin and just lateral to rectus muscle was found on examination. Lab investigations revealed hepatitis B infection with deranged liver functions. Plain X-ray abdomen in revealed free gas shadow under diaphragm. USG revealed distended gallbladder but CT scan showed free gas in peritoneal cavity with distended gallbladder and gas in gallbladder lumen, wall and pericholecystic region settling the final diagnosis of pneumo-cholecystitis. She was clinically stable and no signs of peritonitis were present. Although treatment of choice for pneumo-cholecystitis is splenectomy we postponed surgery due to deranged liver function tests and hepatitis B infection and conservative treatment was used. Patient was discharged after one week and doing well during a follow up of 11 months.
Spontaneous pneumoperitoneum is an extremely rare finding in pneumo-cholecystitis. It should be ascertained that no visceral perforation is present, before proceeding for conservative management.