Introduction: Gangrenous cholecystitis (GC) represents a severe complication of acute cholecystitis, characterized by full-thickness necrosis of the gallbladder wall. This condition arises from persistent cystic duct obstruction, causing local ischemia and inflammation. Its incidence, ranging from 2% to 29.6% of acute cholecystitis cases, is associated with risk factors such as diabetes mellitus (DM), where microvascular disease is believed to increase the likelihood of gangrenous transformation. Diagnosing GC preoperatively remains challenging due to its infrequency and nonspecific symptoms. This report details the case of a 56-year-old male with DM, initially diagnosed with diabetic ketoacidosis (DKA) and later found to have GC despite non-elevated liver function tests, no leukocytosis, and no history of or current right upper quadrant pain on presentation.

Case Presentation: A 56-year-old male, with a history of uncontrolled DM without known neuropathy, presented with shakiness, fever, and chills which began the morning of admission. He reported a 9 month history of non-radiating epigastric abdominal pain now with 1 week worsening and nausea and vomiting. He denied history of or current right upper quadrant pain and post-prandial abdominal pain. On exam, he had moderate epigastric tenderness and negative Murphy’s sign. Ultrasound and CT showed evidence of gallbladder wall thickening, sludge, and cholelithiasis. Given normal white blood cell count, liver function tests (LFTs), and lipase levels, the suspicion for acute cholecystitis was initially low. Patient was found to be hyperglycemic with an anion gap of 19, consistent with DKA, and was admitted. Final Diagnosis: Several days after admission, patient developed post-prandial right upper quadrant pain. He continued to have no leukocytosis, and non-elevated LFTs and lipase. A HIDA scan was performed, which showed evidence of cystic duct obstruction. Decision was made to perform a laparoscopic cholecystectomy, which found GC.

Management/Outcome: The patient’s post-operative course was uneventful, and he was discharged home shortly after. This case underscores the importance of heightened suspicion for GC in diabetic patients, who may lack classic symptoms of acute cholecystitis, such as Murphy’s sign and lab abnormalities. This highlights the importance of a comprehensive diagnostic approach and early operative intervention.

References and Resources

1. Fagan SP, Awad SS, Rahwan K, et al. Prognostic factors for the development of gangrenous cholecystitis. Am J Surg. 2003;186(5):481-485. doi:10.1016/j.amjsurg.2003.08.001.
2. Chiariello, Massimo I Ciro. Silent Myocardial Ischemia in Patients With Diabetes Mellitus. Circulation. 1996;93(12):2089-2091.
3. Callaghan BC, Cheng HT, Stables CL, Smith AL, Feldman EL. Diabetic neuropathy: clinical manifestations and current treatments. Lancet Neurol. 2012;11(6):521-534. doi:10.1016/S1474-4422(12)70065-0.
4. Hirota M, Takada T, Kawarada Y, et al. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg. 2007;14(1):78-82. doi:10.1007/s00534-006-1159-4.
5. Bennett GL, Rusinek H, Lisi V, et al. CT findings in acute gangrenous cholecystitis. AJR Am J Roentgenol. 2002;178(2):275-281. doi:10.2214/ajr.178.2.1780275.
6. Kiewiet JJS, Leeuwenburgh MMN, Bipat S, Bossuyt PMM, Stoker J, Boermeester MA. A Systematic Review and Meta-Analysis of Diagnostic Performance of Imaging in Acute Cholecystitis. Radiology. 2012;264(3):708-720. doi:10.1148/radiol.12111561.