Atypical Presentation of Gangrenous Cholecystitis; a Case Series: 

Safa, Rawan, et al. “Atypical Presentation of Gangrenous Cholecystitis: A Case Series.” American Journal of Emergency Medicine, Elsevier, 16 Aug. 2018,  

https://www.sciencedirect.com/science/article/abs/pii/S0735675718306843

I chose to research an article based on my SOAP note 4, in which I had a patient with a very typical presentation of cholecystitis. Even though my patient was missing certain red light factors such as eating a fatty meal, and positive Murphy sign, he still had typical findings such as a colicky abdominal pain located in the right epigastric area, radiating to the shoulder. I wanted to look into possible atypical presentations of cholecystitis, and what we should be looking out for, and found this study.  

There are many different types of cholecystitis; acute cholecystitis, chronic cholecystitis, acute calculous/acute a calculous cholecystic, as well as gangrene cholecystitis, which is a more serious type. Gangrenous cholecystitis is a complication of acute cholecystitis, or one that has not been treated, in which excessive gall bladder distension causes increased tension and pressure on the gallbladder wall, this leads to occlusion of the arterial supply, and blockage of the cystic duct leading to full thickness ischemic changes, and necrosis and ulcerations of the gallbladder wall; hence the name gangrenous. There is a 10-40% chance of all patients with acute chole, having gangrenous chole, which makes its diagnosis that much more critical.  

In this article, they highlight how those with GC (gangrenous chole) can present in atypical ways, and can have non-specific labs and imagining findings that make this dangerous disease more difficult to diagnose. Risk factors that can increase ones chances of having GC include male gender, being over the age of 45, leukocytosis, and a history of Diabetes and cardiovascular disease. This article is a case series which follows patients with atypical presentations, including one patient who came in for intractable hiccups.  

The main case is about a a 78 year old patient with a PMH of HLD, HTN, and IBS who presents with intractable hiccups for 5 days. He denies any abdominal pain, nausea vomiting, or other symptoms. His vitals are baseline normal, and his physical exam is unremarkable except for mild RUQ discomfort. His labs showed elevated WBCs, and ALK phos. Finally a CT abdomen was done which showed gallbladder distension, wall thickening and inflammatory changes. The patient was given antibiotics and had a cholecystectomy done. In this case it was concluded that the patients intractable hiccups were due to diaphragmatic irritation secondary to the gallbladder inflammation. 

I believe the main takeaway from this article is that certain common and dangerous diseases can present in very different ways, and its important to keep a broad differential list in mind when evaluating a patient. For example, if the Doctors in the case above did not explore the vague abdominal pain more this patient would have had a very poor outcome. A lot of disease disguise themselves as something different, and as clinicians we need to be both well informed and open-minded.