Emphysematous cholecystitis is commonly caused by infective gas-forming bacteria such as Escherichia coli, Klebsiella pneumoniae and Clostridium perfringens. 1 CT is the gold-standard diagnostic modality. 4 Treatment is cholecystectomy with cholecystostomy an alternative for non-surgical candidates. 4 Morbidity and mortality is significantly greater than uncomplicated cholecystitis. 1 A 77-year-old female with an underlying metastatic pancreatic neuroendocrine tumour presented to a Tertiary

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... logy Admission Unit with a 3-week history of increasingly diffuse abdominal pain, fatigue and intermittent loose stools. Initial observations noted no abnormalities but abdominal examination identified tenderness in the right upper quadrant. Murphy's sign was negative, and clinical examination was otherwise unremarkable. Baseline laboratory investigations demonstrated raised C-reactive protein (283), lactate (3.9) and abnormal liver function tests (bilirubin 27, ALP 451, AST 65, GGT 265, LDH 1525), suggesting biliary sepsis. She was empirically treated with intravenous meropenem and a plain abdominal X-ray (AXR) and computed tomography (CT) scan of abdomen and pelvis scan were performed ( Figure 1A and B, respectively) which confirmed emphysematous cholecystitis. Despite the initial management the patient deteriorated further, becoming pyrexial and significantly hypotensive. The patient was taken for emergency cholecystostomy with metaraminol vasopressor support. Biliary cultures obtained during the procedure grew Klebsiella pneumoniae. Following the procedure, she was transferred to the critical care unit for vasopressor support. Despite an initial improvement, she later deteriorated and died 3 weeks post-cholecystostomy secondary to sepsis and progressive cancer. Emphysematous cholecystitis is a rare variant of cholecystitis with a narrow range of causative gas-forming organisms, including Escherichia coli, K. pneumoniae and Clostridium perfringens. 1 It is more commonly related to acalculous cholecystitis. Patients often present with blunted responses to infection including mild, non-specific symptoms of fatigue and upper abdominal discomfort, moderate biochemical and haematological responses and a lack of pyrexia. 2 Signs may be masked further by concomitant immune-suppressive therapy. Plain film may reveal an air-fluid level within the gallbladder, pericholecystic tissue or extrahepatic ducts, pneumobilia or pneumoperitoneum. 3 However, plain films lack both sensitivity and specificity. Ultrasound is better than plain film, with signs such as echogenic foci with reverberation artefact, or a band of acoustic shadowing within the gallbladder fossa. CT is the primary imaging modality for diagnosing emphysematous cholecystitis. CT can show small pockets of gas not otherwise visible on plain films or ultrasound. It is also superior for identifying conditions mimicking emphysematous cholecystitis such as cholecystoenteric fistulation. 4 Treatment is directed at removing the source of infection and bacteraemia. Intravenous antibiotics, cholecystectomy and cholecystostomy are the mainstays of treatment, with the lattermost being reserved for patients too clinically unstable for