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29 Acalculus Cholocystitis
1. Acalculous Cholecystitis
Further reading :
http://emedicine.medscape.com/article/187645-overview
1. Epidemiology
1. Incidence: 5-10% of patients with Acute
Cholecystitis
2. Risk factors
1. Elderly
2. Diabetes Mellitus
3. Multiple trauma
4. Extensive burn injury
5. Prolonged labor
6. Major surgery
7. Gallbladder torsion
8. Systemic Vasculitis
9. Biliary tract infection (Bacterial or parasitic)
3. Symptoms and Signs
1. Indistinguishable from calculous Acute
Cholecystitis
2. Patient ill on initial presentation
4. Diagnostics
1. RUQ Ultrasound or CT Abdomen
1. Large, tense, static gallbladder
2. No evidence of Gallstones
2. Radionuclide Cholescintography (HIDA scan)
1. Poor gallbladder filling
2. Gallbladder ejection fraction <50%
5. Management
1. Cholecystectomy
1. Offers satisfactory symptom relief in
96% of cases
2. Brosseuk (2003) Am J Surg 186:1
2. RUQ Ultrasoun = Gallbladder
Ultrasound
1. Efficacy in Cholelithiasis
1. Test Sensitivity for Gallstones: 95%
2. Test Specificity high
3. Can visualize Gallstones >= 2 mm
2. Evaluation of Cholecystitis
1. Findings suggestive of Cholecystitis
1. Presence of Gallstones
2. Thickened gallbladder wall
3. Gallbladder distension
4. Pericholecystic fluid
5. Positive sonographic Murphy Sign
2. Interpretation: Above findings present
1. Cholecystitis Positive Predictive
Value (PPV) 90%
3. Interpretation: Above findings absent
1. Cholecystitis unlikely
RIGHT UPPER QUADRANT
3. Radionuclide Cholescintography =: HIDA
scan, DISIDA scan
1. Technique
1. Technetium-iminodiacetic acid analog injected
IV
1. HIDA scan used for Serum Bilirubin <
5-7 mg/dl
It is most commonly observed in the setting of very ill
2. DISIDA scan used for Serum Bilirubin
patients (eg, on mechanical ventilation, with sepsis or
>7 mg/dl 1 2
severe burn injuries, after severe trauma ). In addition,
2. Absorbed and secreted into biliary tract by acalculous cholecystitis is associated with a higher
hepatocytes incidence of gangrene and perforation compared to
calculous disease.
The usual finding on imaging studies is a distended
2. Interpretation acalculous gallbladder with thickened walls (>3-4 mm) with
1. Normal Billiary tract and Gallbladder or without pericholecystic fluid. Acalculous cholecystitis can
1. Clear outline gallbladder and cystic be observed in patients with human immunodeficiency virus
duct in 1 hour (HIV) infection, although it is a late manifestation of this
2. Cystic duct obstruction disease. Acalculous cholecystitis can also be found in
1. Failure to outline Gallbladder within 1 patients on total parenteral nutrition (TPN), typically those
hour on TPN for more than 3 months.
Pathophysiology
The main cause of this illness is thought to be due to bile stasis
and increased lithogenicity of bile. Critically ill patients are more
predisposed because of increased bile viscosity due to fever
and dehydration and because of prolonged absence of oral
feeding resulting in a decrease or absence of cholecystokinin-
induced gallbladder contraction. Gallbladder wall ischemia that
occurs because of a low-flow state due to fever, dehydration,
or heart failure may also play a role in the pathogenesis of
acalculous cholecystitis.
4. Management should be instituted promptly, especially in
critically ill patients. After blood cultures are obtained,
intravenous broad spectrum antibiotics should be started.
Once acalculous cholecystitis is established, secondary
infection with enteric pathogens, including Escherichia coli,
Enterococcus faecalis, Klebsiella, Pseudomonas, Proteus
species, and Bacteroides is common. Antibiotic therapy
should be directed against these organisms.
Workup
Laboratory Studies
The choice of antibiotics should take into consideration
CBC count, liver function tests, and blood culture tests are recent use of antibiotics. Patients who were previously on
some of the main laboratory tests that should be broad-spectrum antibiotics can be treated with a third
performed. Bile culture results are negative in nearly 50% generation cephalosporin plus metronidazole or
of patients with acalculous cholecystitis, probably imipenem/cilastatin plus or minus antifungal therapy (usually
because of concurrent antibiotic therapy in these patients with fluconazole) depending upon the duration and intensity
of prior broad spectrum antibiotic therapy. Vancomycin can
be added when the incidence of nosocomial infection with
MRSA is known or suspected to be likely.
Diet
Patients in the acute stage of acalculous cholecystitis should receive
nothing by mouth. Hydration with intravenous fluids should be Those who have not previously received antibiotics can
provided. receive empiric therapy with piperacillin/tazobactam,
ampicillin/sulbactam, or imipenem. Aminoglycosides should
be avoided when possible in the elderly or those with renal
Medication insufficiency, although one or two doses can be given
empirically pending microbiological results in most patients
Administer broad-spectrum antibiotics for enteric and biliary without serious risk.
pathogen coverage. Definitive treatment is cholecystectomy in
patients who are surgical candidates or cholecystostomy in
patients who are not surgical candidates.
Follow-up
Complications
Perforation or gangrene of the gallbladder and extrabiliary
abscess formation may occur.
Prognosis
Prognosis is guarded.
Miscellaneous
Medicolegal Pitfalls
Delay in diagnosis or treatment may result in higher mortality
rates.
