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Related Subjects:Acute Cholecystitis |Acute Appendicitis |Chronic Peritonitis |Abdominal Aortic Aneurysm |Ectopic Pregnancy |Acute Cholangitis |Acute Abdominal Pain/Peritonitis |Assessing Abdominal Pain |Penetrating Abdominal Trauma |Acute Pancreatitis |Acute Diverticulitis

Acalculous cholecystitis is a hypokinetic condition of gallbladder emptying. Usually seen in the context of multiorgan failure in ITU and may require cholecystectomy. CT is the best initial test.

About

• Seen in critically ill patients often older males
• Classical picture of acute cholecystitis but no stones seen
• Prognosis is worse than those with stones

Aetiology

• This is an inflammatory disease of the gallbladder
• No evidence of gallstones or cystic duct obstruction

Associations

• Diabetes, Fasting, TPN, Sepsis
• Post cardiac surgery, abdominal/vascular surgery
• Severe Trauma, Burns, Opiates, IHD
• Human immunodeficiency virus (HIV) infection
• Prolonged fasting or TPN

Clinical

• Patients often very unwell with other illnesses
• RUQ pain, Fever, Positive Murphy's sign

Investigations

• FBC: raised WCC Raised CRP. U&E: maybe an AKI. LFTS - abnormal
• USS: no stones with thickened gallbladder wall (>3-5 mm). May be pericholecystic fluid, failure to visualize gallbladder, perforation w/ abscess, emphysematous cholecystitis
• CT: thickened gallbladder wall (>4 mm) in absence of ascites or hypoalbuminemia, pericholecystic fluid, intramural gas, or sloughed mucosa
• Radionuclide cholescintigraphy (HIDA) scan: failure to opacify gallbladder; sensitivity almost 100%; Acute cholecystitis will result in no filling of the gallbladder with the radionuclide material

Complications

• Sepsis
• Gangrene of the gallbladder
• Perforation of the gallbladder
• Abscess
• ARDS

Differential

• Calculous cholecystitis
• Peptic ulcer disease
• Acute pancreatitis
• Right pyelonephritis
• Liver or subphrenic abscess

Management

• ABC, IV fluids, resuscitate, HDU, Treat with broad spectrum antibiotics. Gangrene and perforation are more common. Urgent cholecystectomy may be indicated which may be open or laparoscopic
• In those patients who are unstable, one may consider the placement of a percutaneous drainage tube in the gallbladder by the radiologist. Another option is Stent placement via ERCP to decompress the gallbladder.
• Patients are often older and frail. Most case reports indicate poor outcomes and even patients who survive have a prolonged recovery period but never attain full functional recovery.

References

• Acalculous Cholecystitis