Acalculous cholecystitis

Background

• Acute necroinflammatory disease of gallbladder with multifactorial pathogenesis
  • Gallbladder stasis and ischemia leads to distension and eventually necrosis/perforation
  • Accounts for 10% of acute cholecystitis; associated with high morbidity/mortality

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Anatomy & Pathophysiology

• Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
• These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
• Bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.

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Gallbladder disease types

Gallbladder anatomy (overview).

Gallbladder anatomy

Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.

• Symptomatic cholelithiasis (biliary colic)
• Choledocholithiasis
• Acute calculous cholecystitis
• Ascending cholangitis
• Acalculous cholecystitis
• Biliary atresia
• Cholestasis of pregnancy

Risk Factors

• Burns
• CAD
• DM
• Immunosuppression
• Infection
• Mechanical ventilation
• Medications (eg, opioids, sunitinib)
• Multiple transfusions
• Nonbiliary surgery
• Sepsis/hypotension
• Vasculitis
• TPN, especially TPN > 3 mo

Clinical Features

• Similar to calculous cholecystitis
• Jaundice is common (20% of patients)

Differential Diagnosis

RUQ Pain

• Gallbladder disease
  • Symptomatic cholelithiasis (biliary colic)
  • Choledocholithiasis
  • Acute cholecystitis
  • Ascending cholangitis
  • Acalculous cholecystitis
• Pancreatitis
• Acute hepatitis
• Pancreatitis
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Bowel obstruction
• Cirrhosis
• Budd-Chiari syndrome
• GU
  • Pyelonephritis
  • Kidney stone
  • Fitz-Hugh-Curtis Syndrome
• Other
  • Hepatomegaly due to CHF
  • Peptic ulcer disease with or without perforation
  • Pneumonia
  • Herpes zoster
  • Myocardial ischemia
  • Pulmonary embolism
  • Abdominal aortic aneurysm

Evaluation

Work-Up

• CBC
  • Leukocytosis (70-85% of patients)
• Chemistry
• LFTs
  • Hyperbilirubinemia
  • Alk phos elevation (mild)
  • Transaminitis
• Blood cultures
• RUQ Ultrasound
  • Absence of gallstones or sludge
  • Thickened wall (>5 mm) with pericholecystic fluid
  • Positive sonographic Murphy's sign
  • Emphysematous cholecystitis with gas bubbles arising in fundus of gallbladder
  • Frank perforation of gallbladder with associated abscess formation

Management

• Antibiotics
  • Ceftriaxone + metronidazole OR
  • Piperacillin/tazobactam
• Cholecystectomy
  • Definitive therapy

Disposition

• Admit

See Also

• Gallbladder Disease (Main)