Acute acalculous cholecystitis refers to the development of cholecystitis in a gallbladder either without gallstones or with gallstones where they are not the contributory factor. It is thought to occur most often due to biliary stasis and/or gallbladder ischemia.
Acute acalculous cholecystitis represents 5-10% of cases of acute cholecystitis.
Acute acalculous cholecystitis usually occurs in critically ill or injured patients (e.g. trauma, burns, sepsis). Ischemia/reperfusion injury to the gallbladder is a central pathogenic feature. Other contributory factors include 9:
- bile stasis, e.g. from various causes of cystic duct obstruction
- opioid therapy
- positive-pressure ventilation (PPV)
- total parenteral nutrition (TPN)
- cocaine-related (rare)
- advanced age and cerebrovascular accidents 12
- major surgery (e.g. heart valves), trauma, and burns 13
A rare cause of acalculous cholecystitis occurring in patients with advanced cancer is gallbladder metastases 10.
When there are no gallstones, the diagnosis is more obvious.
May show gallbladder wall edema, pericholecystic fluid, and gallbladder distention (the first two considered the two most important criteria 2). The sonographic Murphy's sign may be positive. A sonolucent intramural layer or “halo” that represents intramural edema may also be present.
Tc-99m iminodiacetic acid cholescintigraphy is considered a highly reliable test and may be performed even in acutely ill patients. Ideally, there is non-visualization of the gallbladder.
Treatment and prognosis
The importance of recognizing acalculous cholecystitis lies in the fact that these patients have a high rate of recurrence when treated with medical management. As such, cholecystectomy is the definitive treatment. However, patients that are not fit for surgery can undergo percutaneous or endoscopic biliary drainage as alternative therapy, though cholecystectomy may still be performed when the patient improves.
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