Acalculous Cholecystitis

Gallbladder inflammation in absence of obstruction that leads to ischaemia and subsequent necrosis, biliary gangrene, and septic shock. Strongly associated with critical illness, in particular severe:

Epidemiology and Risk Factors

Risk Factors for Acalculous Cholecystitis
Category Strong Weak
Patient
  • Obesity
Disease
  • Trauma
  • Burns
  • Sepsis
  • Critical illness
  • Vasculitis
  • CBD obstruction
  • Diabetes
  • Hypertension
Treatment
  • Surgery
  • TPN
  • ERCP
  • Immunosuppression
Other
  • Fasting
  • Prolonged hospital stay

Pathophysiology

Disease develops due to a combination of:

  • Gallbladder ischaemia
    Leading to gangrenous areas. Due to:
    • ↓ Splanchnic blood flow
      • Shock
  • Bile stasis
    Leads to biliary distension. Due to lack of normal gall bladder contraction and emptying.
  • ↑ Bile viscosity
    Leading to high concentration of bile salts and bile stasis. Due to:
    • Volume depletion
    • Dehydration
    • Bile stasis
      Results in further ↑ in bile viscosity.

Clinical Features

  • Fever
  • Abdominal pain
  • RUQ mass
  • RUQ crepitus
  • Jaundice
    Rarely.

Diagnostic Approach and DDx

Investigations

Laboratory:

  • Blood
    • FBE
      • Leukocytosis
    • LFTs
      Cholestatic picture.
    • Blood cultures

Imaging:

  • Ultrasound
    Features include:
    • Distension
      >5cm.
    • Thickened wall
      >3.5mm.
    • Pericholecystic fluid
    • No gallstones
    • Hyperdense biliary sludge
    • Gas in wall
      Indicating gas forming anaerobes present.
    • Gas in gallbladder
      “Champagne sign”.
    • Gall bladder perforation
  • CT
    Similar accuracy to ultrasound, with similar findings.
  • Cholescintigraphy
    • Most sensitive
    • Can quantify gallbladder ejection fraction
    • Low utility in the critically ill due to the hours-long test time

Management

  • Standard sepsis management
    Covered under .
  • Intra-abdominal antibiotic cover
  • Procedural intervention in selected cases
    • Low-risk cases can be treated effectively with antibiotics alone
    • High-risk cases may be so morbid so as to preclude cholecystectomy
      Percutaneous cholecystotomy remains an option in many of these.

Specific therapy:

  • Pharmacological
    • Antibiotics
      One of:
      • Tazocin 4.5g IV Q6-8H
      • Meropenem 1g IV Q8H
      • Cefepime 2g IV Q8H, metronidazole 500mg IV Q8H, and ampicillin 2g IV Q4H or vancomycin
    • Antifungal
      May be reasonable in the critically unwell, discuss with ID.
  • Procedural
    A spectrum of procedural options, listed by morbidity:
    • Percutaneous cholecystotomy
      • Lowest complication rate
      • Definitive management in 80% of cases
      • Risk of drain dislodgement
    • Laparoscopic cholecystectomy
      • Definitive management
      • Risk of conversion to open
    • Open cholecystectomy
      • Definitive management
      • Facilitates thorough abdominal washout
        e.g. Perforated gallbladder.
      • Highly morbid in the critically ill
        Up to 20% mortality.

Antibiotic regimen chosen should cover streptococci, enterococci, Enterobacteriaceae, P. aeruginosa, and anaerobes such as Bacteroides.

Supportive care:

  • C
    • Volume resuscitation
  • D
    • Analgesia
    • Antiemetics

Marginal and Ineffective Therapies

Anaesthetic Considerations

Complications

  • I
    • Intraabdominal sepsis
      Perforation occurs in ~10%.

Prognosis

Key Studies

References

  1. Bersten, A. D., & Handy, J. M. (2018). Oh’s Intensive Care Manual. Elsevier Gezondheidszorg.