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

Risk Factors

• Burns
• CAD
• DM
• Immunosuppression
• Infection
• Mechanical ventilation
• Medications (eg, opiates, sunitinib)
• Multiple transfusions
• Nonbiliary surgery
• Sepsis/hypotension
• Vasculitis

Clinical Features

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

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

Work-Up

1. CBC
2. Chemistry
3. LFTs
4. Blood cx
5. Ultrasound

Diagnosis

• Leukocytosis (70-85% of pts)
• LFT abnormalities
  • Hyperbilirubinemia
  • Alk phos elevation (mild)
  • Transaminitis
• Ultrasound findings:
  • Absence of gallstones or sludge
  • Thickened wall (>5 mm) with pericholecystic fluid
  • Positive sonographic Murphy's sign
  • Emphysematous cholecystitis w/ gas bubbles arising in fundus of gallbladder
  • Frank perforation of gallbladder with associated abscess formation

Treatment

1. Abx
   1. Ceftriaxone + metronidazole OR
   2. Piperacillin/tazobactam
2. Cholecystectomy
   1. Definitive therapy

Disposition

• Admit

See Also

Gallbladder Disease (Main)

Source

• UpToDate