Acute acalculous cholecystitis
Acute acalculous cholecystitis refers to the development of cholecystitis either in a gallbladder without gallstones or in a gallbladder with gallstones where the stones are not the contributory factor. It is thought most often due to biliary stasis and/or gallbladder ischaemia.
Acute acalculous cholecystitis represents 5-10% of acute cholecystitis cases.
Acute acalculous cholecystitis usually occurs in critically ill or injured patients (e.g. trauma, burns, sepsis). Ischaemia/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)
When there are no gallstones, the diagnosis is easier.
May show gallbladder wall oedema with pericholecystic fluid with gallbladder distention (the former two considered two most important criteria 2). The sonographic Murphy's sign may be positive. A sonolucent intramural layer or “halo” that represents intramural oedema may also be present.
Tc-99m iminodiacetic acid cholescintigraphy is considered a highly reliable test and may be performed even in acutely ill patients. There is usually non-visualisation 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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