- Nezam H Afdhal, MD, FRCPI
Nezam H Afdhal, MD, FRCPI
- Senior Physician in Hepatology
- Beth Israel Deaconess Medical Center
- Section Editors
- Stanley W Ashley, MD
Stanley W Ashley, MD
- Section Editor — Pancreatic and Hepatobiliary Surgery
- Chief Medical Officer and Senior Vice President for Clinical Affairs
- Brigham and Women’s Hospital
- Frank Sawyer Professor of Surgery
- Harvard Medical School
- Keith D Lindor, MD
Keith D Lindor, MD
- Section Editor — Alcoholic and Metabolic Liver Disease
- Professor of Medicine, Mayo Clinic College of Medicine
- Dean, College of Health Solutions
- Arizona State University
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 high morbidity and mortality rates.
This topic will review the pathophysiology, diagnosis, and treatment of acalculous cholecystitis. Clinical issues related to acute calculous cholecystitis are discussed separately. (See "Acute cholecystitis: Pathogenesis, clinical features, and diagnosis" and "Treatment of acute calculous cholecystitis".)
The conditions associated with acalculous cholecystitis (table 1) lead to gallbladder stasis and ischemia, which then result in a local inflammatory response in the gallbladder wall. In the majority of patients, multiple risk factors are present [1-7]. Pathologically, there is endothelial injury, gallbladder ischemia, and stasis, leading to concentration of bile salts, gallbladder distension, and eventually necrosis of the gallbladder tissue. Once acalculous cholecystitis is established, secondary infection with enteric pathogens, including Escherichia coli, Enterococcus faecalis, Klebsiella, Pseudomonas, Proteus species, and Bacteroides, is common . Perforation occurs in severe cases [9,10].
While secondary infection of the gallbladder is common, in some cases, specific primary infections predispose to acalculous cholecystitis and should be managed appropriately (table 2). As an example, acalculous cholecystitis occurring in patients with acquired immunodeficiency syndrome (AIDS) and other immunosuppressed patients may be due to opportunistic infections such as microsporidia, Cryptosporidium, or cytomegalovirus . More often, however, these infections cause a cholangiopathy without cholecystitis. (See "AIDS cholangiopathy".)
Acalculous cholecystitis is typically seen in patients who are hospitalized and critically ill, though it may also be seen in the outpatient setting. Acalculous cholecystitis has been reported in 0.7 to 0.9 percent of patients following open abdominal aortic reconstruction, in 0.5 percent of patients following cardiac surgery, and in as many as 4 percent of patients who have undergone bone marrow transplantation [4,12-15]. There is a strong male predominance among patients with acute cholecystitis following surgery in the absence of trauma (80 percent) .To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Shapiro MJ, Luchtefeld WB, Kurzweil S, et al. Acute acalculous cholecystitis in the critically ill. Am Surg 1994; 60:335.
- Gofrit O, Eid A, Pikarsky A, et al. Cholesterol embolisation causing chronic acalculous cholecystitis. Eur J Surg 1996; 162:243.
- Schwesinger WH, Diehl AK. Changing indications for laparoscopic cholecystectomy. Stones without symptoms and symptoms without stones. Surg Clin North Am 1996; 76:493.
- Wiboltt KS, Jeffrey RB Jr. Acalculous cholecystitis in patients undergoing bone marrow transplantation. Eur J Surg 1997; 163:519.
- Romero Ganuza FJ, La Banda G, Montalvo R, Mazaira J. Acute acalculous cholecystitis in patients with acute traumatic spinal cord injury. Spinal Cord 1997; 35:124.
- Nash JA, Cohen SA. Gallbladder and biliary tract disease in AIDS. Gastroenterol Clin North Am 1997; 26:323.
- McChesney JA, Northup PG, Bickston SJ. Acute acalculous cholecystitis associated with systemic sepsis and visceral arterial hypoperfusion: a case series and review of pathophysiology. Dig Dis Sci 2003; 48:1960.
- Wang AJ, Wang TE, Lin CC, et al. Clinical predictors of severe gallbladder complications in acute acalculous cholecystitis. World J Gastroenterol 2003; 9:2821.
- Venkataramani A, Strong RM, Anderson DS, et al. Abnormal duodenal bile composition in patients with acalculous chronic cholecystitis. Am J Gastroenterol 1998; 93:434.
- Janowitz P, Kratzer W, Zemmler T, et al. Gallbladder sludge: spontaneous course and incidence of complications in patients without stones. Hepatology 1994; 20:291.
- Wind P, Chevallier JM, Jones D, et al. Cholecystectomy for cholecystitis in patients with acquired immune deficiency syndrome. Am J Surg 1994; 168:244.
- Barie PS. Acalculous and postoperative cholecystitis. In: Surgical intensive care, Barie PS, Shires GT (Eds), Little Brown & Co, Boston 1993. p.837.
- Ouriel K, Green RM, Ricotta JJ, et al. Acute acalculous cholecystitis complicating abdominal aortic aneurysm resection. J Vasc Surg 1984; 1:646.
- Hagino RT, Valentine RJ, Clagett GP. Acalculous cholecystitis after aortic reconstruction. J Am Coll Surg 1997; 184:245.
- Cadot H, Addis MD, Faries PL, et al. Abdominal aortic aneurysmorrhaphy and cholelithiasis in the era of endovascular surgery. Am Surg 2002; 68:839.
- Savoca PE, Longo WE, Zucker KA, et al. The increasing prevalence of acalculous cholecystitis in outpatients. Results of a 7-year study. Ann Surg 1990; 211:433.
- Ryu JK, Ryu KH, Kim KH. Clinical features of acute acalculous cholecystitis. J Clin Gastroenterol 2003; 36:166.
- Kalliafas S, Ziegler DW, Flancbaum L, Choban PS. Acute acalculous cholecystitis: incidence, risk factors, diagnosis, and outcome. Am Surg 1998; 64:471.
- Adams DB, Tarnasky PR, Hawes RH, et al. Outcome after laparoscopic cholecystectomy for chronic acalculous cholecystitis. Am Surg 1998; 64:1.
- Jagannath SB, Singh VK, Cruz-Correa M, et al. A long-term cohort study of outcome after cholecystectomy for chronic acalculous cholecystitis. Am J Surg 2003; 185:91.
- Faust TW, Reddy KR. Postoperative jaundice. Clin Liver Dis 2004; 8:151.
- Laméris JS, van Overhagen H. Imaging and intervention in patients with acute right upper quadrant disease. Baillieres Clin Gastroenterol 1995; 9:21.
- Molenat F, Boussuges A, Valantin V, Sainty JM. Gallbladder abnormalities in medical ICU patients: an ultrasonographic study. Intensive Care Med 1996; 22:356.
- Barie PS, Eachempati SR. Acute acalculous cholecystitis. Gastroenterol Clin North Am 2010; 39:343.
- Westlake PJ, Hershfield NB, Kelly JK, et al. Chronic right upper quadrant pain without gallstones: does HIDA scan predict outcome after cholecystectomy? Am J Gastroenterol 1990; 85:986.
- Mariat G, Mahul P, Prév t N, et al. Contribution of ultrasonography and cholescintigraphy to the diagnosis of acute acalculous cholecystitis in intensive care unit patients. Intensive Care Med 2000; 26:1658.
- Mirvis SE, Whitley NO, Miller JW. CT diagnosis of acalculous cholecystitis. J Comput Assist Tomogr 1987; 11:83.
- Mirvis SE, Vainright JR, Nelson AW, et al. The diagnosis of acute acalculous cholecystitis: a comparison of sonography, scintigraphy, and CT. AJR Am J Roentgenol 1986; 147:1171.
- Cornwell EE 3rd, Rodriguez A, Mirvis SE, Shorr RM. Acute acalculous cholecystitis in critically injured patients. Preoperative diagnostic imaging. Ann Surg 1989; 210:52.
- DuPriest RW Jr, Khaneja SC, Cowley RA. Acute cholecystitis complicating trauma. Ann Surg 1979; 189:84.
- Hamp T, Fridrich P, Mauritz W, et al. Cholecystitis after trauma. J Trauma 2009; 66:400.
- Yang HK, Hodgson WJ. Laparoscopic cholecystostomy for acute acalculous cholecystitis. Surg Endosc 1996; 10:673.
- Boland GW, Lee MJ, Leung J, Mueller PR. Percutaneous cholecystostomy in critically ill patients: early response and final outcome in 82 patients. AJR Am J Roentgenol 1994; 163:339.
- McLoughlin RF, Patterson EJ, Mathieson JR, et al. Radiologically guided percutaneous cholecystostomy for acute cholecystitis: long-term outcome in 50 patients. Can Assoc Radiol J 1994; 45:455.
- Sugiyama M, Tokuhara M, Atomi Y. Is percutaneous cholecystostomy the optimal treatment for acute cholecystitis in the very elderly? World J Surg 1998; 22:459.
- vanSonnenberg E, D'Agostino HB, Goodacre BW, et al. Percutaneous gallbladder puncture and cholecystostomy: results, complications, and caveats for safety. Radiology 1992; 183:167.
- England RE, McDermott VG, Smith TP, et al. Percutaneous cholecystostomy: who responds? AJR Am J Roentgenol 1997; 168:1247.
- Davis CA, Landercasper J, Gundersen LH, Lambert PJ. Effective use of percutaneous cholecystostomy in high-risk surgical patients: techniques, tube management, and results. Arch Surg 1999; 134:727.
- Akhan O, Akinci D, Ozmen MN. Percutaneous cholecystostomy. Eur J Radiol 2002; 43:229.
- Lee MJ, Saini S, Brink JA, et al. Treatment of critically ill patients with sepsis of unknown cause: value of percutaneous cholecystostomy. AJR Am J Roentgenol 1991; 156:1163.
- Lo LD, Vogelzang RL, Braun MA, Nemcek AA Jr. Percutaneous cholecystostomy for the diagnosis and treatment of acute calculous and acalculous cholecystitis. J Vasc Interv Radiol 1995; 6:629.
- Joseph T, Unver K, Hwang GL, et al. Percutaneous cholecystostomy for acute cholecystitis: ten-year experience. J Vasc Interv Radiol 2012; 23:83.
- Chung YH, Choi ER, Kim KM, et al. Can percutaneous cholecystostomy be a definitive management for acute acalculous cholecystitis? J Clin Gastroenterol 2012; 46:216.
- Saeed SA, Masroor I. Percutaneous cholecystostomy (PC) in the management of acute cholecystitis in high risk patients. J Coll Physicians Surg Pak 2010; 20:612.
- Spira RM, Nissan A, Zamir O, et al. Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis. Am J Surg 2002; 183:62.
- Hadas-Halpern I, Patlas M, Knizhnik M, et al. Percutaneous cholecystostomy in the management of acute cholecystitis. Isr Med Assoc J 2003; 5:170.
- Huibregtse K, van Amerongen R, van Deventer SJ. Drainage of the gallbladder in patients with acute acalculous cholecystitis by transpapillary endoscopic cholecystoxeransis. Gastrointest Endosc 1994; 40:523.
- Barie PS, Eachempati SR. Acute acalculous cholecystitis. Curr Gastroenterol Rep 2003; 5:302.
- Barie PS, Hydo LJ, Pieracci FM, et al. Multiple organ dysfunction syndrome in critical surgical illness. Surg Infect (Larchmt) 2009; 10:369.
- CLINICAL MANIFESTATIONS
- Physical examination
- Laboratory tests
- When to consider acalculous cholecystitis
- Blood cultures
- Abdominal radiograph
- Cholescintigraphy (HIDA scan)
- Computed tomography
- DIFFERENTIAL DIAGNOSIS
- Endoscopic drainage
- SUMMARY AND RECOMMENDATIONS