Acalculous Cholecystitis

Background

An inflammatory disease of the gallbladder without evidence of gallstones or cystic duct obstruction; it is an illness that is a complication of various other medical or surgical conditions. Duncan first recognized it in 1844 when a fatal case of acalculous cholecystitis complicating an incarcerated hernia was reported. The condition causes approximately 5-10% of all cases of acute cholecystitis and is usually associated with more serious morbidity and higher mortality rates than calculous cholecystitis. It is most commonly observed in the setting of very ill patients. Acalculous cholecystitis is associated with a higher incidence of gangrene and perforation compared to calculous cholecystitis.

Pathophysiology

The main cause is thought to be bile stasis and increased lithogenicity of bile. Critically ill patients are more predisposed because of increased bile viscosity due to dehydration. Gallbladder wall ischemia due to a low-flow state caused by dehydration, or heart failure may also have a role in the pathogenesis of acalculous cholecystitis.

Etiology

The main cause of acalculous cholecystitis is gallbladder stasis with resulting stagnant bile.

Mortality/Morbidity and Complications

The mortality and morbidity rates associated with acalculous cholecystitis can be high. It is frequently observed in patients with sepsis and other serious conditions. The reported mortality range is 10-50% for acalculous cholecystitis as compared to 1% for calculous cholecystitis.

Perforation or gangrene of the gallbladder and extrabiliary abscess formation are the main complications.

History and Physical Examination

History findings are of limited value. Physical examination can show fever and right upper quadrant tenderness.

Diagnostic Considerations

• Sepsis with biliary tract infection
• AIDS
• Total parenteral nutrition – associated liver disease

Treatment

MEDICAL

There is a high risk of rapid deterioration and gallbladder perforation. That indicates immediate intervention.

In patients with acalculous cholecystitis who are high-risk surgical candidates endoscopic gallbladder stent placement may be an effective palliative treatment. It involves placement of a double pigtail stent between the gallbladder and the duodenum during endoscopic retrograde cholangiopancreatography (ERCP). However, the definitive treatment of acalculous cholecystitis is cholecystectomy for patients who are able to tolerate surgery.

In selected patients with acute acalculous cholecystitis, nonsurgical treatment (such as antibiotics or percutaneous cholecystostomy) may be an effective alternative to surgery.

Surgical Care

In surgical candidates, open or laparoscopic cholecystectomy is indicated for acute cholecystitis.

In patients who are not surgical candidates, percutaneous cholecystostomy may be performed. This procedure may be the safest and most successful intervention in patients who are critically ill, with multiple comorbidities. Catheters are usually removed after approximately 3 weeks in critically ill patients with acalculous cholecystitis who have undergone percutaneous cholecystostomy. This allows for the development of a mature track from the skin to the gallbladder.

Medication

Administer broad-spectrum antibiotics with enteric and biliary pathogen coverage. Definitive treatment is cholecystectomy for patients who are surgical candidates or cholecystostomy for patients who are not.