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Pneumoperitoneum and Right Upper Quadrant Gas in a Diabetic Man

Charles F. Butler, MD; Herbert L. Fred, MD; Victor Carlson, MD
JAMA. 1976;236(24):2789-2790. doi:10.1001/jama.1976.03270250053033.
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History  An 86-year-old man experienced anorexia and vomiting for three days. His previous health had been good. On examination, he was acutely ill and had scleral icterus, diffuse abdominal tenderness, and fever to 39 C.His total white blood cell count was 24,000/cu mm; blood glucose concentration, 600 mg/100 ml; and urine glucose, 4 +. Roentgenographic studies included a chest film and a spot film of the right upper quadrant of the abdomen (Fig 1 and 2).

Diagnosis  Emphysematous cholecystitis.

Comment  Chest roentgenogram (Fig 1) shows a right upper lobe infiltrate, air beneath the right hemidiaphragm, and a poorly depicted gas-fluid level in the gallbladder region. To clarify the gasfluid level, the abdominal film (Fig 2) was obtained. Gas outlines the major bile ducts (arrows) and gallbladder.After receiving antibiotics and fluids for one day, the patient successfully underwent removal of a distended gangrenous gallbladder, which contained foul-smelling pus and a


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