The illustrated case demonstrates the importance of placing arterial pseudoaneurysms on the differential diag- noses of posttraumatic masses. The variability of the time course, mode of injury, and symptoms necessitates a High clinical suspicion, as the incision and drainage of such lesions can result in life-threatening consequences. Algo- rithms of the diagnoses and management of such lesions indicate Angiographic examination followed by repair; however, prompt recognition remains paramount to reduce morbidity and mortality.

Ani Aydin SUNY Stony Brook School of Medicine Stony Brook, NY 11794, USA

Christopher C. Lee MD Eric Schultz MD Jeremy Ackerman MD

Department of Emergency Medicine Stony Brook University Hospital Stony Brook, NY 11794, USA

E-mail address: christolee@notes.cc.sunysb.edu

doi:10.1016/j.ajem.2006.11.015

References

1. Herber SC, Ajalat GM, Smith DC, Hinshaw Jr DB, Killeen Jr JD. Transcatheter embolization facilitating surgical management of a giant Inferior gluteal artery pseudoaneurysm. J Vasc Surg 1998;8(6): 716 – 20.
2. Agarwal M, Giannoudis PV, Syed AA, Hinsche AF, Matthews SJ, Smith RM. Pseudoaneurysm of the inferior gluteal artery following polytrauma: diverse presentation of a dangerous complication: a report of two cases. J Orthop Trauma 2003;17(1):70 – 4.
3. Williams Jr W, Jackson Jr GF, Greene C. superior gluteal artery aneurysm. J Trauma 1997;17(6):477 – 9.
4. Gilroy D, Saadia R, Hide G, Demetriades D. penetrating injury to the gluteal region. J Trauma 1992;32(3):294 – 7.
5. Barker SG, Anthony AA, Pillay SS, Porter AJ, Davies RP, Jury P. Sporting ‘groin strains’: not always muscular!. Aust N Z J Surg 1995; 65(6):451 – 3.
6. Kaplan JL, Challenor Y. Posttraumatic osseous tunnel formation causing sciatic nerve entrapment. Arch Phys Med Rehabil 1993;74(5):552 – 4.
7. Mikulin T, Walker EW. False aneurysm following blunt trauma. Injury 1984;15(5):309 – 10.
8. Papadopoulos SM, McGillicuddy JE, Messina LM. Pseudoaneurysm of the inferior gluteal artery presenting as sciatic nerve compression. Neurosurgery 1989;24(6):926 – 8.
9. Bennett JD, Brown TC, Coates CF, MacKenzie D, Sweeney J. Pseudoaneurysm of the inferior gluteal artery. Can Assoc Radiol J 1992;43(4):296 – 8.

Case Report

Acute emphysematous cholecystitis with initial normal radiological evaluation: a fatal diagnostic pitfall in the ED

Acute emphysematous cholecystitis is a relatively rare disease, a severe variant of acute cholecystitis, that

predominantly affects elderly diabetic men. The apparently high mortality and morbidity associated with acute emphy- sematous cholecystitis have previously emphasized the importance of Prompt diagnosis and emergent surgical intervention. Radiological evaluation including plain ab- dominal radiograph (KUB), abdominal sonography, and computed tomography of abdomen is the cornerstone of diagnosis of acute emphysematous cholecystitis. We de- scribe a nonDiabetic woman who developed sepsis due to acute emphysematous cholecystitis with rapid deterioration within 24 hours. She was misdiagnosed as having Peptic ulcer disease initially due to normal KUB, abdominal sonography, and computed tomography of abdomen.

Case report

A 69-year-old nondiabetic woman was brought to the emergency department (ED) because of Epigastric pain for 2 hours. She had history of peptic ulcer disease. The pain persisted without vomiting and diarrhea. Notably, she was afebrile (35.68C). The following initial vital signs were stable: blood pressure, 140/58 mm Hg; pulse rate, 71 beats/min; and respiratory rate, 18 breaths/min. Physical examination showed mild tenderness at epigastric area without obvious Murphy sign. Blood test revealed slight leukocytosis (white blood cell count, 10,000/mm³) and normal hepatobiliary values (glucose, 112 mg/dL; aspartate aminotransferase , 23 U/L; total bilirubin, 0.4 mg/ dL; lipase, 33 U/L). Both KUB and Bedside sonography showed no significant finding. Abdominal computed tomography was arranged to determine the nature of the acute abdomen but was negative as well (Fig. 1). After observation for several hours with improved symptoms,

Fig. 1 Initial abdominal computed tomography showed no obvious finding.

she was discharged with the possible diagnosis of peptic ulcer disease.

Unfortunately, she returned to the ED with sepsis 8 hours after discharge due to recurrent epigastric pain. She was found to have fever (38.58C), tachycardia (115 beats/min), and normal blood pressure (129/62 mm Hg). Physical examination showed severe tenderness at epigastric area. Left decubitus abdominal x-ray was taken approximately 24 hours after the previous abdominal computed tomogra- phy for ruled out Peptic ulcer perforation. It incidentally showed characteristic gallbladder distention, a circumferen- tial gallbladder wall gas lucency, and an intraluminal air fluid level (Fig. 2). Acute emphysematous cholecystitis was highly suspected then. Abdominal sonography showed gas- forming lesion near gallbladder with nonvisible gallbladder. Repeated abdominal computed tomography confirmed our suspicion (Fig. 3), and she underwent emergent open cholecystectomy. Acalculous, ischemic, and Gangrenous gallbladder was found. The patient recovered well after surgical intervention.

Acute emphysematous cholecystitis is a relatively rare disease, a severe variant of acute cholecystitis, which exists with several differences compared with simple acute cholecystitis. It predominantly affects elderly men (men forming 71% of patients with emphysematous cholecystitis but only 27% in acute cholecystitis). A high incidence of diabetes mellitus (up to 50%) and high frequency of acalculous cholecystitis were noted too. The mortality rate for uncomplicated acute cholecystitis is approximately 1.4%. The mortality rate for acute emphysematous cholecystitis, however, is 15% to 20%, owing to the increased incidence of gallbladder wall gangrene and perforation in these patients. This variance emphasizes

Fig. 2 Plain abdominal radiograph showed circumferential gallbladder wall gas lucency with intraluminal air-fluid level.

Fig. 3 Abdominal computed tomography showed emphysema- tous cholecystitis.

the importance of prompt diagnosis and emergent surgical intervention [1-3].

Radiological evaluation including plain KUB, abdominal sonography, and computed tomography of the abdomen is the cornerstone of diagnosis of acute emphysematous cholecystitis; indeed, there is no report of diagnosis being made through high clinical suspicion without a radiological workup. Laboratory tests are nonspecific and might only show indirect evidence of acute Systemic Infection, such as leukocytosis [4,5]. This makes the early diagnosis of acute emphysematous cholecystitis challenging for any emergen- cy physician.

The fatal diagnostic pitfall in this patient was that she presented to the ED with no fever, relatively normal blood test, normal KUB, normal abdominal sonography, and even normal abdominal computed tomography initially. Furthermore, she is a nondiabetic woman, which consid- erably lowered the index of suspicion for acute emphyse- matous cholecystitis. She returned within 24 hours with severe gangrenous emphysematous cholecystitis, an insid- ious and rapidly progressive disease with probable fatal outcome [6].

In conclusion, acute emphysematous cholecystitis should be kept in mind as a cause of epigastric pain even in an afebrile, nonDiabetic patient with a negative thorough preliminary imaging (plain KUB, abdominal sonography, and abdominal computed tomography) to avoid missing this curable but rapidly progressing fatal disease.

Vei-Ken Seow MD Chiu-Mei Lin PhD, MD Emergency Department

Shin-Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan, ROC

Tzong-Luen Wang PhD, MD Chee-Fah Chong MS, MD

I-Yin Lin MD

Emergency Department Shin-Kong Wu Ho-Su Memorial Hospital

Taipei, Taiwan, ROC Fu Jen Catholic University

E-mail address: liniyin889@hotmail.com

doi:10.1016/j.ajem.2006.11.023

References

1. Bedirli A, Sakrak O, Sozuer EM, et al. Factors effecting the complications in the natural history of acute cholecystitis. Hepatogas- troenterology 2001;48:1275 – 8.
2. Garcia-Sancho Tellez L, Rodriguez-Montes JA, Fernandez De Lis S, et al. Acute emphysematous cholecystitis. Report of twenty cases. Hepatogastroenterology 1999;46:2144 – 8.
3. Mentzer RM, Golden GT, Chandler JG, et al. A comparative appraisal of emphysematous cholecystitis. Am J Surg 1975;129:10 – 5.
4. de Araujo DB, Renck DV, de Britto MAP, et al. Emphysematous cholecystitis: an Unusual presentation of a rare disease. MJM 2004;8:28 – 30.
5. Gill KS, Chapman AH, Weston MJ, et al. The changing face of emphysematous cholecystitis. Br J Radiol 1997;70:986 – 91.
6. Yeatman TJ. Emphysematous cholecystitis: an insidious variant of acute cholecystitis. Am J Emerg Med 1988;4:163 – 6.