acalculous cholecystitis

Introduction

cholecystitis without obstructive cholelithiasis

Etiology

• hospitalized critically ill patients
• burns
• advanced atherosclerosis
• infections
  • AIDS
  • Cytomegalovirus
  • Salmonella
• rheumatologic disease
  • polyarteritis nodosa
  • systemic lupus erythematosus

Epidemiology

• 10% of acute cholecystitis
• 0.2% of all critically ill patients

Pathology

• gallbladder ischemia
• chronic stasis of bile in the gallbladder as a result of underlying disease
• inflammation & distension of the gallbladder wall
• pericystic fluid collection
• enteric bacterial infection due to ascending cholangitis

Clinical manifestations

• right upper quadrant pain
• fever
• leukocytosis, jaundice & sepsis in sedated mechanically-ventilated patients

Laboratory

• complete blood count (CBC): leukocytosis
• liver function tests
  • mildly elevated serum transaminases
  • elevated serum alkaline phosphatase
  • serum bilirubin may be noraml or mildly elevated
• serum creatinine is normal

Diagnostic procedures

• abdominal ultrasound has better diagnostic accuracy than abdominal CT
  • repeat RUQ abdominal ultrasound even if done a week prior if acalculous cholecystitis due to critcal illness suspected
• endoscopic ultrasound takes longer than RUQ abdominal ultrasound

Radiology

• abdominal CT
• HIDA scan
• magnetic resonance cholangiopancreatography if ultrasound is not diagnostic

Complications

• cholangitis, empyema, gangrene, &/or gallbladder perforation in 50%
• infection with enteric bacteria
• mortality 10-50%

Management

• cholecystectomy
• percutaneous drainage of gallbladder (cholecystostomy) if cholestectomy is contraindicated (i.e. seriously ill patient)
• intraveous antibiotics for coverage of enteric anaerobes & gram-negative bacteria

More general terms

• cholecystitis