Makindo Medical Notes

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 an inflammatory condition of the gallbladder characterized by impaired emptying without the presence of gallstones. It usually occurs in critically ill patients, often in the context of multiorgan failure in the intensive care unit (ICU), and may require cholecystectomy. Computed tomography (CT) is the preferred initial imaging test.

About

• Occurs in critically ill patients, often older males.
• Presents similarly to acute cholecystitis but without gallstones.
• Associated with a worse prognosis compared to calculous cholecystitis.

Aetiology

• An inflammatory disease of the gallbladder.
• Occurs without evidence of gallstones or cystic duct obstruction.

Associations

• Diabetes mellitus.
• Sepsis.
• Prolonged fasting or total parenteral nutrition (TPN).
• Post cardiac, abdominal, or vascular surgery.
• Severe trauma or burns.
• Use of opiates.
• Ischemic heart disease (IHD).
• Human immunodeficiency virus (HIV) infection.

Clinical

• Patients are often very unwell with multiple comorbidities.
• Symptoms include right upper quadrant (RUQ) pain, fever, and a positive Murphy's sign.

Investigations

• Blood Tests: Elevated white cell count (WCC), raised C-reactive protein (CRP), possible acute kidney injury (AKI) on U&E, abnormal liver function tests (LFTs).
• Ultrasound (USS): Thickened gallbladder wall (>3–5 mm) without gallstones. May show pericholecystic fluid, failure to visualize the gallbladder, perforation with abscess, or emphysematous cholecystitis.
• Computed Tomography (CT): Thickened gallbladder wall (>4 mm) in the absence of ascites or hypoalbuminemia, pericholecystic fluid, intramural gas, or sloughed mucosa.
• Radionuclide Cholescintigraphy (HIDA scan): Failure to opacify the gallbladder; sensitivity is almost 100%. In acute cholecystitis, there is no filling of the gallbladder with the radionuclide material.

Complications

• Sepsis.
• Gangrene of the gallbladder.
• Perforation of the gallbladder.
• Abscess formation.
• Acute respiratory distress syndrome (ARDS).

Differential Diagnosis

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

Management

• Provide supportive care: airway, breathing, circulation (ABC), intravenous fluids, resuscitation, and monitoring in a high-dependency unit (HDU).
• Treat with broad-spectrum antibiotics.
• Urgent cholecystectomy may be indicated; can be performed open or laparoscopically.
• In unstable patients, consider percutaneous gallbladder drainage performed by a radiologist.
• Endoscopic retrograde cholangiopancreatography (ERCP) with stent placement to decompress the gallbladder may be another option.
• Prognosis is often poor, especially in older and frail patients. Recovery may be prolonged with incomplete functional return.

References

• Acalculous Cholecystitis