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

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.

Gallbladder disease types

Gallbladder anatomy (overview).

Gallbladder anatomy

• Symptomatic cholelithiasis (biliary colic)
• Choledocholithiasis
• Acute calculous cholecystitis
• Ascending cholangitis
• Acalculous cholecystitis

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
• Peptic ulcer disease with or without perforation
• Pancreatitis
• Acute hepatitis
• Pyelonephritis
• Pneumonia
• Kidney stone
• Pancreatitis
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Fitz-Hugh-Curtis Syndrome
• Hepatomegaly due to CHF
• Herpes zoster
• Myocardial ischemia
• Bowel obstruction
• Pulmonary embolism
• Abdominal aortic aneurysm

Evaluation

Longitudinal ultrasound of gallbladder with thickened wall and mild pericholecystic fluid (arrows). The common bile duct was normal (not shown).

CT showing gallbladder wall thickening and pericholecystic liquid, without gallbladder lithiasis.

Work-Up

• CBC
• Chemistry
• LFTs
• Blood cultures
• RUQ Ultrasound

Diagnosis

• CBC
  • Leukocytosis (70-85% of patients)
• LFTs
  • Hyperbilirubinemia
  • Mildly elevated alkaline phosphatase
  • Transaminitis
• 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)