Acalculous cholecystitis
Acalculous cholecystitis is acute gallbladder inflammation without gallstones, driven by ischemia and biliary stasis in critically ill, fasting, or TPN-dependent patients. Ultrasound showing gallbladder wall thickening or pericholecystic fluid without stones supports the diagnosis. Untreated mortality reaches 75 percent, so treatment starts with intravenous antibiotics plus percutaneous cholecystostomy, followed by cholecystectomy once the patient stabilizes.
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What this article covers
- Overview
Acalculous cholecystitis is acute gallbladder inflammation without gallstones or cystic duct obstruction.
- Epidemiology
Acalculous cholecystitis occurs almost exclusively in patients who are already critically ill: those in an intensive care unit (ICU) after major trauma, extensive burns, cardiac surgery, or a cardiac…
- Risk factors
Critical illness and prolonged fasting: any condition that keeps a patient nil by mouth removes the cholecystokinin-driven gallbladder contraction that normally prevents bile stasis.
- Pathophysiology
Two processes combine to cause acalculous cholecystitis: bile stasis and gallbladder wall ischemia.
- Clinical features
Alert patients: present much like calculous cholecystitis, with right upper quadrant (RUQ) or epigastric pain, nausea, RUQ tenderness, and often a positive Murphy sign.
- Differential diagnosis
Calculous acute cholecystitis: the near-identical sibling, but ultrasound shows gallstones or sludge obstructing the cystic duct, whereas acalculous disease shows wall thickening or pericholecystic fluid without any stone.
- Diagnosis
The diagnosis is established by combining the high-risk clinical setting, a critically ill, fasting, sedated, or TPN-dependent patient, with sonographic findings of gallbladder wall thickening…
- Management
First, resuscitate and obtain blood cultures, then start empiric intravenous antibiotics with gram-negative and anaerobic coverage: piperacillin-tazobactam 3.375 g IV every 6 hours.
- Complications
Gallbladder gangrene and perforation: the wall injury from ischemia progresses to necrosis and full-thickness perforation faster than in calculous disease, since there is no antecedent stone to slow the process.
- Prognosis
Untreated disease carries a mortality of up to 75%, which is why early recognition and prompt source control take priority over any single diagnostic test.
- Prevention
Favor early enteral nutrition over TPN when the gastrointestinal tract is functional, starting within 24 to 48 hours of ICU admission when feasible, since enteral feeding preserves the…
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Related articles
- Acute cholecystitis
Acute cholecystitis is inflammation of the gallbladder from cystic duct obstruction, most often by a gallstone, presenting with RUQ pain lasting more than 6 hours, fever, and a positive Murphy sign. Diagnosis follows the Tokyo Guidelines TG18 criteria and severity grade, and treatment combines IV antibiotics with early laparoscopic cholecystectomy, or cholecystostomy in patients too unstable for surgery.
- Choledocholithiasis
Choledocholithiasis is a gallstone that has migrated into the common bile duct, causing obstructive jaundice and cholestatic liver chemistries and predisposing to acute cholangitis and gallstone pancreatitis. Risk is stratified by ASGE criteria and confirmed by MRCP, endoscopic ultrasound, or therapeutic ERCP, which clears the duct before same-admission cholecystectomy.
- Acute cholangitis
Acute cholangitis is a bacterial infection of an obstructed biliary tree, classically presenting as Charcot triad of fever, right upper quadrant pain, and jaundice and progressing to septic shock when drainage is delayed. Diagnosis follows the Tokyo Guidelines and severity grade, and treatment combines prompt broad-spectrum antibiotics with biliary drainage, most often by ERCP.
- Sepsis
Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection, identified by an acute rise in SOFA score of 2 points or more in a patient with known or suspected infection. Survival depends on recognizing the pattern early and completing the hour-1 bundle: lactate, blood cultures before antibiotics, broad-spectrum antibiotics such as cefepime 2 g IV every 8 hours, and 30 mL/kg crystalloid for hypotension or a lactate of 4 mmol/L or higher.
- Septic shock
Septic shock is the subset of sepsis with hypotension requiring vasopressors to maintain a mean arterial pressure above 65 mm Hg plus a serum lactate above 2 mmol/L despite adequate fluid resuscitation, carrying in-hospital mortality of 40% or higher. Management is a timed sequence: 30 mL/kg crystalloid bolus, blood cultures and broad-spectrum antibiotics within 1 hour, norepinephrine titrated to MAP >=65, and escalation to a second vasopressor and stress-dose hydrocortisone when hypotension persists.