emphysematous cholecystitis ( ec ) is an uncommon variant of acute cholecystitis , which is caused by secondary infection of the gallbladder wall with gas - forming organisms [ 15 ] . the mortality rate of ec is as high as 25% because of its high complication rate [ 2 , 5 ] due to gangrene , gallbladder perforation , pericholecystic abscess and bile peritonitis . emergency surgical intervention is necessary for ec treatment for which open cholecystectomy has traditionally been performed [ 1 , 35 ] . here a 78-year - old male was admitted to our hospital for an investigation of vertigo . after admission , he developed fever and abdominal distention . a chest x - ray in the up - right position and abdominal computed tomography ( ct ) the chest x - ray showed the presence of gas within the gallbladder and in its wall ( fig .  1 ) . the ct scan revealed emphysematous changes in the gallbladder wall and air within the gallbladder ( fig . the patient was referred to the department of surgery and emergent surgery was performed . figure  1:up - right chest x - ray demonstrating air in the gallbladder ( arrow ) and in its wall ( arrowheads ) . figure  2:(a  and b ) abdominal computed tomographic scans of axial and coronal views revealing emphysematous changes in the gallbladder wall and air in the gallbladder . up - right chest x - ray demonstrating air in the gallbladder ( arrow ) and in its wall ( arrowheads ) . ( a  and b ) abdominal computed tomographic scans of axial and coronal views revealing emphysematous changes in the gallbladder wall and air in the gallbladder . based on the hemodynamically stable status of the patient , we selected a laparoscopic approach . exploration of the abdominal cavity revealed gangrene and necrosis of the gallbladder . to facilitate the resection , we initially punctured the gallbladder using a percutaneous needle to extract bile . although there was significant adhesion , we were able to safely dissect the calot 's triangle and detected a cystic duct and artery . his postoperative course was uneventful . a bile culture obtained during surgery revealed clostridium perfringens , enterobacter cloacae and enterococcus faecalis as the causative organisms . ec is an uncommon variant of acute cholecystitis characterized by potentially high mortality and morbidity because of a high incidence of gangrene or perforation . garcia et al .   reviewed 20 cases of ec and reported that the mortality rate was as high as 25% and the morbidity rate as high as 50% . emergent surgical intervention for ec is indicated with cholecystectomy as the definitive treatment , although percutaneous cholecystostomy for critically ill patients presents another option [ 1 , 4 , 5 ] . bouras et al .   reported that the laparoscopic approach for ec can be considered a safe procedure . owing to the advances of laparoscopic surgery , it has allowed to perform emergency cholecystectomy . our patient was hemodynamically stable ; therefore , we selected the laparoscopic approach , which was successfully and safely completed . the causative organisms of ec include c. perfringens , escherichia coli and species of the genera staphylococcus , streptococcus , pseudomonas and klebsiella [ 15 ] . ec is associated with diabetes mellitus and primarily affects males , as in the present case . the symptoms of ec are almost the same as those of acute cholecystitis , including right upper quadrant pain , nausea , vomiting and low - grade fever [ 2 , 4 ] . a prompt diagnosis of ec is essential and plain abdominal x - rays or ultrasound can be diagnostically useful with a sensitivity of up to 95% . however , contrast - enhanced abdominal ct scans may offer more information . in our patient , a chest x - ray in the up - right position detected air in the gallbladder wall and an abdominal ct revealed typical presentation of ec . emergency intervention is indicated and the laparoscopic approach can be considered a safe and effective method in hemodynamically stable patients .