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

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

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
  • Alk phos elevation (mild)
  • 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)