Successful Conservative Management of Emphysematous Cholecystitis in a Non-Diabetic Elderly Patient with Multiple Comorbidities

Abstract

Background: Emphysematous cholecystitis (EC) is a rare, fulminant variant of acute cholecystitis caused by gas-forming organisms in the setting of gallbladder ischemia and impaired mucosal defenses. It typically affects elderly diabetic men and carries a high mortality rate, particularly when associated with Clostridium perfringens. Although urgent cholecystectomy is considered the standard of care, emerging evidence suggests that early-stage EC may occasionally be managed non-operatively in carefully selected high-risk patients.

Case Presentation: A 79-year-old non-diabetic male with coronary artery disease, prior cerebrovascular accident, acute kidney injury, and hyperlipidemia presented with right upper quadrant pain and nausea. Laboratory studies revealed leukocytosis, markedly elevated CRP, and impaired renal function. Contrast-enhanced CT demonstrated Type I emphysematous cholecystitis with intraluminal gas but no mural involvement, pericholecystic extension, gallstones, or perforation. Due to his high surgical risk, the patient was treated conservatively with IV piperacillin–tazobactam, fluid resuscitation, and close hemodynamic monitoring. On day two, he developed hypotension, oliguria, and rising inflammatory markers, prompting escalation to meropenem. Following antibiotic adjustment, he exhibited continuous clinical and biochemical improvement, with normalization of renal function and resolution of inflammatory markers. Repeat imaging confirmed complete resolution, and the patient was discharged on day ten in stable condition.

Conclusion: This case demonstrates that early-stage emphysematous cholecystitis may be successfully managed with antibiotics alone in non-diabetic patients with significant vascular comorbidities when prompt diagnosis, close monitoring, and appropriate antimicrobial escalation are ensured. Early CT imaging and individualized, stage-based decision-making are essential to avoid progression to gangrene, perforation, or sepsis, particularly in high-risk patients and resource-limited environments.