title: Emphysematous cholecystitis presenting as gas-forming liver abscess and pneumoperitoneum in a dialysis patient: a case report and review of the literature.
abstract: BACKGROUND
  Emphysematous cholecystitis is a rare variant of acute cholecystitis with a high mortality rate. The combination of emphysematous cholecystitis, liver abscess and pneumoperitoneum are even rarer. Herein we present a case of emphysematous cholecystitis in a senile diabetic lady who had worsening hemodynamics while undergoing hemodialysis.
  
  
  METHODS
  A 64-year-old woman with history of type 2 diabetes mellitus and end stage renal disease with regular hemodialysis presented to the emergency department with a 1-day history of sudden onset of lassitude and hypotension during hemodialysis. The result of a computed tomography (CT)-scan revealed air encircling the gallbladder, liver parenchymal and minimal pneumoperitoneal and liver abscess with no cholelithiasis. The patient had received empirical antibiotics with piperacillin-tazobactam 2.25 g intravenous route every 6 h for 14 days and cholecystectomy with surgical debridement and lead an uneventful postoperative hospital course. Escherichia coli was demonstrated as well as blood culture and peritoneal fluid culture.
  
  
  CONCLUSIONS
  In a senile diabetic and dialysis patient, we should take emphysematous cholecystitis into consideration once vague abdominal pain occurrs. Empirical antibiotic therapy and adequate surgical intervention should take place as soon as possible.
authors.affiliation: Department of Medicine, Kaohsiung Armed Forces General Hospital, No.2, Zhongzheng 1st Rd, Lingya Dist, Kaohsiung City, 802, Taiwan R.O.C. ericliao0217@gmail.com.|Department of Internal medicine, Division of Nephrology, Tri-service general hospital, National defense Medical center, No.325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan R.O.C. ericliao0217@gmail.com.
authors.forename: Chen-Yi
authors.initials: CY
authors.lastname: Liao
authors.affiliation: Department of Medicine, Kaohsiung Armed Forces General Hospital, No.2, Zhongzheng 1st Rd, Lingya Dist, Kaohsiung City, 802, Taiwan R.O.C. chi12017@gmail.com.
authors.forename: Chi-Chang
authors.initials: CC
authors.lastname: Tsai
authors.affiliation: Department of Medicine, Kaohsiung Armed Forces General Hospital, No.2, Zhongzheng 1st Rd, Lingya Dist, Kaohsiung City, 802, Taiwan R.O.C. wuhsienku@gmail.com.
authors.forename: Wu-Hsien
authors.initials: WH
authors.lastname: Kuo
authors.affiliation: Department of Medicine, Kaohsiung Armed Forces General Hospital, No.2, Zhongzheng 1st Rd, Lingya Dist, Kaohsiung City, 802, Taiwan R.O.C. benrjbridge@gmail.com.
authors.forename: Ren-Jy
authors.initials: RJ
authors.lastname: Ben
authors.affiliation: Department of Medicine, Kaohsiung Armed Forces General Hospital, No.2, Zhongzheng 1st Rd, Lingya Dist, Kaohsiung City, 802, Taiwan R.O.C. knnonn@yahoo.com.tw.
authors.forename: Ho-Cheng
authors.initials: HC
authors.lastname: Lin
authors.affiliation: Department of Medicine, Kaohsiung Armed Forces General Hospital, No.2, Zhongzheng 1st Rd, Lingya Dist, Kaohsiung City, 802, Taiwan R.O.C. tsgh11@gmail.com.
authors.forename: Ching-Chang
authors.initials: CC
authors.lastname: Lee
authors.affiliation: Department of Medicine, Kaohsiung Armed Forces General Hospital, No.2, Zhongzheng 1st Rd, Lingya Dist, Kaohsiung City, 802, Taiwan R.O.C. modern0827@gmail.com.
authors.forename: Kuan-Jen
authors.initials: KJ
authors.lastname: Su
authors.affiliation: Department of Internal medicine, Division of Nephrology, Tri-service general hospital, National defense Medical center, No.325, Section 2, Cheng-Kung Road, Neihu 114, Taipei, Taiwan R.O.C. hiliangu1204@yahoo.com.
authors.forename: Han-En
authors.initials: HE
authors.lastname: Wang
authors.affiliation: Department of Medicine, Kaohsiung Armed Forces General Hospital, No.2, Zhongzheng 1st Rd, Lingya Dist, Kaohsiung City, 802, Taiwan R.O.C. ndmcndmcndmc@gmail.com.
authors.forename: Chih-Chiang
authors.initials: CC
authors.lastname: Wang
authors.affiliation: Department of Medicine, Kaohsiung Armed Forces General Hospital, No.2, Zhongzheng 1st Rd, Lingya Dist, Kaohsiung City, 802, Taiwan R.O.C. nephrooil@gmail.com.
authors.forename: I-Hung
authors.initials: IH
authors.lastname: Chen
authors.affiliation: Department of Pathology, Kaohsiung Armed Forces General Hospital, Kaohsiung, Taiwan R.O.C. chienstkl@gmail.com.
authors.forename: Shang-Tao
authors.initials: ST
authors.lastname: Chien
authors.affiliation: Department of Medicine, Kaohsiung Armed Forces General Hospital, No.2, Zhongzheng 1st Rd, Lingya Dist, Kaohsiung City, 802, Taiwan R.O.C. tmk802@gmail.com.
authors.forename: Ming-Kai
authors.initials: MK
authors.lastname: Tsai
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D002763:Cholecystectomy; D003646:Debridement; D003924:Diabetes Mellitus, Type 2 / Q000150:complications; D041882:Emphysematous Cholecystitis / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D004927:Escherichia coli Infections / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D005260:Female; D006801:Humans; D007676:Kidney Failure, Chronic / Q000150:complications / Q000628:therapy*; D008100:Liver Abscess / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D008875:Middle Aged; D011027:Pneumoperitoneum / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D006435:Renal Dialysis; D014057:Tomography, X-Ray Computed
chemical_list: D000900:Anti-Bacterial Agents