Acalculous cholecystitis

INTRODUCTION

Acalculous cholecystitis is an acute necroinflammatory disease of the gallbladder with a multifactorial pathogenesis. It accounts for approximately 10 percent of all cases of acute cholecystitis and is associated with a high morbidity and mortality.

The pathophysiology, diagnosis, and treatment of acalculous cholecystitis. will be reviewed here. Clinical issues related to acute calculous cholecystitis are discussed separately.

CLINICAL MANIFESTATIONS

Acalculous cholecystitis is strongly associated with a variety of clinical conditions (table 1) [1-7]. The clinical presentation is variable, and often depends upon the underlying predisposing conditions. In the critically ill, who may be intubated and sedated, the appearance of unexplained fever, leukocytosis, or vague abdominal discomfort may be the only clue, and warrants a high suspicion for the disease. The insidious presentation in such cases is associated with a high incidence of gallbladder gangrene and perforation. The complications may be manifested by sepsis, shock, and peritonitis.

The disease can also occur in outpatients or in the critically ill who are able to provide a more detailed history [8]. In such cases, the presentation may be similar to that seen in calculous cholecystitis, with severe right upper quadrant pain radiating to the right side with associated fever, tenderness, and a positive Murphy's sign (pain elicited during inspiration while palpating the right upper quadrant) [9].

The proportion of cases occurring in outpatients is not well-defined. In one of the largest single center reports describing this distinction, 36 of 47 patients (77 percent) identified over a seven year period developed symptoms at home without evidence of acute illness or trauma [10]. Significant vascular disease was observed in 72 percent of these patients. Although this suggests that the relative incidence in outpatients may be much higher than is generally recognized, some of these patients may have been mislabeled as having acalculous cholecystitis since it is possible that gallstones or microcrystals had not been appreciated.