Global research trends in emphysematous cholecystitis: a pubmed-based bibliometric analysis

Authors

Abstract

AimThis study aimed to perform a comprehensive bibliometric analysis of the scientific literature on emphysematous cholecystitis indexed in the PubMed database.
MethodsA retrospective bibliometric analysis was conducted using the PubMed database. Publications related to emphysematous cholecystitis published until May 2026 were identified using predefined search terms. English-language studies involving human subjects were included. Bibliometric variables including publication year, country of origin, journal, publication type, keywords, thematic focus, and imaging modality were analyzed.
ResultsA total of 112 publications published between 1975 and 2026 were included in the analysis. The majority of publications consisted of case reports (54.5%), followed by case series (16.1%) and review articles (11.6%). Annual scientific production demonstrated a progressive increase over time, particularly after 2010. The United States was the leading contributing country with 38 publications (33.9%), followed by Japan and India. The most frequently occurring keywords included “emphysematous cholecystitis,” “computed tomography,” and “diabetes mellitus.” Imaging diagnosis represented the most common thematic research area (36.6%). Computed tomography was the dominant imaging modality reported in the literature (65.2%). Network visualization analyses demonstrated limited multicenter collaboration and relatively fragmented international research networks.
ConclusionScientific interest in emphysematous cholecystitis has increased substantially in recent years, with research predominantly focused on imaging diagnosis, emergency surgical management, and septic complications. The current evidence base remains largely composed of case reports and small institutional studies. Future multicenter collaborative investigations are needed to strengthen the evidence base and improve standardization of management strategies in emphysematous cholecystitis.

Keywords

Introduction

Emphysematous cholecystitis is a rare but potentially life-threatening variant of acute cholecystitis characterized by the presence of gas within the gallbladder wall, lumen, or surrounding tissues due to infection with gas-forming microorganisms. Compared with uncomplicated acute cholecystitis, emphysematous cholecystitis is associated with substantially higher rates of gallbladder gangrene, perforation, sepsis, and mortality. Early diagnosis and prompt intervention are therefore critical for improving clinical outcomes.^1,2
The disease is most observed in elderly individuals and patients with diabetes mellitus, reflecting the important role of vascular compromise and impaired host immunity in disease pathogenesis. Clinical presentation is often nonspecific, ranging from mild abdominal pain to severe septic shock, which may delay diagnosis in emergency and surgical settings. Because of its rapidly progressive nature, emphysematous cholecystitis remains an important clinical entity in emergency medicine, radiology, gastroenterology, and hepatobiliary surgery.^1,2
Radiological imaging plays a central role in diagnosis, particularly computed tomography, which is considered the most sensitive imaging modality for detecting intramural or intraluminal gas and associated complications. Advances in imaging technologies and increasing accessibility of emergency abdominal computed tomography have likely contributed to improved recognition and reporting of emphysematous cholecystitis in recent decades. In parallel, evolving management strategies including early laparoscopic cholecystectomy, intensive care support, and percutaneous cholecystostomy have expanded the therapeutic approaches available for high-risk patients.^2,3,4
Despite the clinical importance of emphysematous cholecystitis, the available literature remains relatively limited and predominantly consists of case reports and small case series because of the rarity of the disease. Consequently, the global research landscape, thematic evolution, collaborative patterns, and publication trends related to emphysematous cholecystitis have not been systematically evaluated.
Bibliometric analysis is a quantitative research method that enables evaluation of publication trends, influential journals, collaborative networks, thematic developments, and scientific productivity within a specific field. Such analyses provide valuable insights into the evolution of scientific interest and help identify current research hotspots and knowledge gaps.^5,6,7 Although bibliometric studies have been conducted in various surgical and gastroenterological diseases, no comprehensive bibliometric analysis focusing specifically on emphysematous cholecystitis has been reported to date.
Therefore, the present study aimed to perform a comprehensive PubMed-based bibliometric analysis of emphysematous cholecystitis literature by evaluating publication trends, leading countries and journals, keyword networks, thematic research areas, and international collaboration patterns.

Materials and Methods

Study DesignThis bibliometric study was conducted to evaluate global publication trends, research characteristics, and thematic developments related to emphysematous cholecystitis. The study design was based on a retrospective bibliometric analysis of publications indexed in the PubMed database.
Data Source and Search StrategyA comprehensive literature search was performed in the PubMed database to identify publications related to emphysematous cholecystitis. The following search terms were used:
("emphysematous cholecystitis"[Title/Abstract]) OR ("acute emphysematous cholecystitis"[Title/Abstract])
The final search was conducted in May 2026. No publication year restriction was applied. Only studies published in English and involving human subjects were included in the analysis.
Eligibility CriteriaPublications focusing on emphysematous cholecystitis were considered eligible for inclusion. Case reports, case series, original research articles, review articles, and imaging-focused publications were included.
The exclusion criteria were:
• duplicate publications,
• non-English articles,
• animal or experimental studies,
• conference abstracts,
• editorials,
• commentaries,
• and publications unrelated to emphysematous cholecystitis.
Study SelectionAll retrieved records were screened independently according to title and abstract relevance. Eligible articles underwent full bibliographic evaluation. After exclusion of irrelevant and duplicate records, the remaining studies were included in the final bibliometric analysis. The study selection process is summarized in Figure 1.
Data ExtractionThe following bibliometric variables were extracted from each publication:
• publication year,
• country of origin,
• journal name,
• publication type,
• keywords,
• thematic focus,
• imaging modality,
• and citation-related characteristics.
Additionally, thematic classifications including imaging diagnosis, surgical management, diabetes mellitus-related studies, septic complications, minimally invasive treatment approaches, and emergency management were evaluated.
Bibliometric AnalysisBibliometric analyses were performed to evaluate:
• annual scientific production,
• leading contributing countries,
• most productive journals,
• frequently occurring keywords,
• thematic research areas,
• and collaboration networks.
Keyword co-occurrence analysis and international collaboration mapping were performed using VOSviewer software (Leiden University, Leiden, Netherlands). Network visualization maps were generated to identify relationships among keywords and contributing countries.
Ethical ApprovalNot applicable.
Statistical AnalysisDescriptive statistics were used to summarize bibliometric characteristics. Categorical variables were expressed as numbers and percentages. Annual publication trends and thematic distributions were analyzed descriptively. Visualization analyses were presented using network mapping figures and publication trend graphs.
Reporting GuidelinesNot applicable.

Results

A total of 128 records related to emphysematous cholecystitis were initially identified through the PubMed database search. After exclusion of duplicate, irrelevant, and non-English publications, 112 articles published between 1975 and 2026 were included in the final bibliometric analysis (Figure 1).
The majority of included publications consisted of case reports (n=61, 54.5%), followed by case series (n=18, 16.1%), review articles (n=13, 11.6%), original research articles (n=11, 9.8%), imaging-focused articles (n=6, 5.4%), and letters/editorials (n=3, 2.7%). These findings indicate that the literature on emphysematous cholecystitis is predominantly composed of descriptive and case-based publications.
Annual scientific production demonstrated a gradual increase over time. Publication activity remained relatively limited until the early 2000s, followed by a progressive increase after 2010. The highest publication output was observed between 2020 and 2025, indicating growing academic interest in emphysematous cholecystitis and advances in diagnostic imaging techniques (Figure 2).
Geographical analysis revealed that the United States was the leading contributor to the literature with 38 publications (33.9%), followed by Japan with 17 publications (15.2%) and India with 12 publications (10.7%). Turkey ranked fourth with 8 publications (7.1%). Contributions predominantly originated from tertiary academic centers and university-affiliated hospitals (Table 1).
Keyword co-occurrence analysis identified “emphysematous cholecystitis,” “acute cholecystitis,” “computed tomography,” and “diabetes mellitus” as the most frequently occurring terms. Additional commonly associated keywords included “gas-forming infection,” “emergency surgery,” “gallbladder perforation,” and “septic shock” (Table 2). Network visualization demonstrated strong clustering between imaging-related terms, metabolic disorders, and surgical management strategies (Supplement Figure ).
Analysis of journals demonstrated that publications were mainly distributed across radiology, surgery, hepatobiliary surgery, and emergency medicine journals. The American Journal of Roentgenology was the most productive journal with 9 publications, followed by the Journal of Gastrointestinal Surgery and HPB Surgery (Supplement Table 1).
Thematic analysis revealed that imaging diagnosis represented the most common research area, accounting for 36.6% of publications. Surgical management (28.6%), diabetes mellitus-related studies (21.4%), and septic complications/sepsis (18.8%) were also prominent thematic categories (Table 3). Recent studies increasingly focused on minimally invasive treatment approaches and image-guided interventions.
Computed tomography was the dominant imaging modality used in published studies, reported in 73 publications (65.2%). Ultrasound was used in 21 publications (18.7%), whereas magnetic resonance imaging was reported less frequently. These findings emphasize the central role of computed tomography in the diagnosis and management of emphysematous cholecystitis.
Citation analysis demonstrated that highly cited publications primarily focused on radiological diagnosis, emergency surgical intervention, and management of severe complications. Common clinical themes included rapid diagnosis, emergency cholecystectomy, septic shock management, and mortality reduction strategies (Supplement Table 2).
International collaboration analysis revealed relatively fragmented research networks with limited multicenter collaboration. Most studies originated from isolated institutional experiences or single-center case-based reports. However, collaborative interactions were most prominent between the United States, Japan, India, and several European countries (Supplement Figure 2).

Discussion

To the best of our knowledge, this study represents the first comprehensive bibliometric analysis specifically evaluating the global scientific literature on emphysematous cholecystitis. The present analysis demonstrated a gradual increase in scientific publications over recent decades, particularly after 2010, suggesting growing academic and clinical interest in this rare but potentially fatal biliary disease. The observed increase in publication activity likely reflects improvements in radiological imaging, broader accessibility of computed tomography in emergency settings, and increasing awareness regarding the severe complications associated with emphysematous cholecystitis.^8,9 In addition, the rising number of publications in recent years may indicate expanding recognition of the disease among emergency physicians, radiologists, surgeons, and intensivists.
One of the most notable findings of the present study was the predominance of case reports and small case series within the literature. More than half of all included publications consisted of individual case reports, while large observational studies and multicenter investigations were relatively uncommon. This finding is not unexpected given the rarity of emphysematous cholecystitis and its relatively low incidence compared with uncomplicated acute cholecystitis.^10,11 However, the predominance of descriptive publications also highlights an important limitation within the current evidence base. Most available knowledge regarding diagnosis, clinical progression, imaging findings, and management strategies continues to rely on isolated institutional experiences rather than high-level evidence. Consequently, substantial heterogeneity exists in diagnostic approaches, therapeutic decision-making, and reported outcomes across literature.
The keyword co-occurrence analysis demonstrated that computed tomography and diabetes mellitus were among the most strongly associated terms within literature. This finding is clinically meaningful because diabetes mellitus has long been recognized as one of the major predisposing factors for emphysematous cholecystitis due to impaired tissue perfusion, vascular compromise, and susceptibility to gas-forming infections.^4,12 Similarly, the dominant role of computed tomography identified in the present analysis reflects the critical importance of imaging in establishing rapid diagnosis. Unlike conventional acute cholecystitis, emphysematous cholecystitis may present nonspecific clinical findings, making radiological evaluation particularly essential. Computed tomography is highly sensitive for detecting intramural gas, pericholecystic air, perforation, and associated septic complications, which likely explains why imaging-related publications represented the most common thematic research area identified in our study.^1,3,13
Another important finding of the present study was the predominance of publications originating from the United States, Japan, and India. These countries collectively accounted for a substantial proportion of the global literature on emphysematous cholecystitis. Several factors may explain this distribution, including higher scientific productivity, broader access to advanced imaging modalities, and the presence of large tertiary referral centers managing complex hepatobiliary emergencies. In addition, the relatively high contribution from Asian countries may reflect the increasing prevalence of diabetes mellitus and aging populations, both of which are recognized risk factors for emphysematous cholecystitis. Despite these contributions, the international collaboration network analysis demonstrated relatively fragmented research patterns with limited multicenter cooperation. Most publications were produced by single institutions or small research groups, emphasizing the need for larger collaborative studies and international registries to improve the evidence base in this field.
The thematic analysis revealed that imaging diagnosis and surgical management represented the dominant research areas within literature. Historically, emphysematous cholecystitis has been considered a surgical emergency because of its association with rapid clinical deterioration, gallbladder gangrene, perforation, and septic shock.^1,2 Accordingly, many highly cited publications focused on emergency cholecystectomy, perioperative management, and mortality reduction strategies. However, the present bibliometric analysis also demonstrated an increasing emphasis on minimally invasive approaches such as percutaneous cholecystostomy and image-guided interventions in recent years. This trend likely reflects evolving management strategies for elderly or critically ill patients who may not tolerate immediate surgery.^4,12 The growing focus on less invasive treatment options suggests an ongoing shift toward individualized and risk-adapted management approaches in contemporary clinical practice.
The citation analysis performed in the present study demonstrated that the most influential publications primarily focused on radiological diagnosis, emergency intervention, and severe septic complications. This finding underscores the central clinical concern surrounding emphysematous cholecystitis, namely the need for rapid recognition and timely management to prevent mortality. Highly cited articles frequently emphasized early computed tomography evaluation, prompt antibiotic therapy, and urgent surgical consultation.^2,3 Furthermore, many influential reports highlighted the atypical or subtle presentation of the disease, particularly in elderly and diabetic patients, which may contribute to diagnostic delay.^1,14,15 The continued prominence of these themes within highly cited publications suggests that early diagnosis and aggressive management remain the cornerstone issues in emphysematous cholecystitis research and clinical care.

Limitations

Several limitations of the present study should be acknowledged. First, the analysis was limited to the PubMed database; therefore, publications indexed exclusively in other databases such as Scopus, Web of Science, or Embase may not have been captured. Second, only English-language publications were included, which may have introduced language bias and potentially underestimated contributions from non-English-speaking countries. Third, bibliometric analyses are inherently dependent on database indexing accuracy and citation dynamics, both of which may change over time. Additionally, because emphysematous cholecystitis is a rare disease, the available literature largely consists of case reports and small retrospective studies, limiting the overall strength and generalizability of the evidence. Despite these limitations, the present study provides a comprehensive overview of the current scientific landscape and research trends related to emphysematous cholecystitis.

Conclusion

In conclusion, the present bibliometric analysis demonstrated a progressive increase in scientific interest regarding emphysematous cholecystitis over recent decades, with research predominantly focused on imaging diagnosis, emergency surgical management, and severe septic complications. Computed tomography emerged as the central diagnostic modality, while diabetes mellitus remained one of the most strongly associated clinical factors within the literature. Although the current evidence base is largely composed of case reports and small institutional experiences, recent trends indicate growing interest in minimally invasive management strategies and multidisciplinary approaches. Future multicenter and collaborative studies are needed to strengthen the available evidence, improve standardization of management strategies, and enhance clinical outcomes in patients with emphysematous cholecystitis.

Declarations

Abbreviations

CT: Computed tomography
EC: Emphysematous cholecystitis
MRI: Magnetic resonance imaging
VOSviewer: Visualization of similarities viewer

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About This Article

Received:

May 20, 2026

Accepted:

June 15, 2026

Published Online:

June 19, 2026