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acalculous cholecystitis

cholecystitis without obstructive cholelithiasis Etiology: - hospitalized critically ill patients - burns - advanced atherosclerosis - infections - AIDS - Cytomegalovirus - Salmonella - rheumatologic disease - polyarteritis nodosa - systemic lupus erythematosus Epidemiology: - 10% of acute cholecystitis - 0.2% of all critically ill patients Pathology: - gallbladder ischemia [1] - chronic stasis of bile in the gallbladder as a result of underlying disease - inflammation & distension of the gallbladder wall - pericystic fluid collection - enteric bacterial infection due to ascending cholangitis Clinical manifestations: - right upper quadrant pain - fever - leukocytosis, jaundice & sepsis in sedated mechanically-ventilated patients Laboratory: - complete blood count (CBC): leukocytosis - liver function tests - mildly elevated serum transaminases - elevated serum alkaline phosphatase - serum bilirubin may be noraml or mildly elevated - serum creatinine is normal Special laboratory: - abdominal ultrasound has better diagnostic accuracy than abdominal CT - repeat RUQ abdominal ultrasound even if done a week prior if acalculous cholecystitis due to critcal illness suspected [4] - endoscopic ultrasound takes longer than RUQ abdominal ultrasound [4] Radiology: - abdominal CT - HIDA scan - magnetic resonance cholangiopancreatography if ultrasound is not diagnostic [1] Complications: - cholangitis, empyema, gangrene, &/or gallbladder perforation in 50% [1] - infection with enteric bacteria [1] - mortality 10-50% Management: - cholecystectomy - percutaneous drainage of gallbladder (cholecystostomy) if cholestectomy is contraindicated (i.e. seriously ill patient) [1,3] - intraveous antibiotics for coverage of enteric anaerobes & gram-negative bacteria

General

cholecystitis

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 16, 18, 19. American College of Physicians, Philadelphia 2012, 2018, 2021.
  2. Huffman JL, Schenker S. Acute acalculous cholecystitis: a review. Clin Gastroenterol Hepatol. 2010 Jan;8(1):15-22 PMID: 19747982
  3. Simorov A, Ranade A, Parcells J et al Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study. Am J Surg. 2013 Dec;206(6):935-40; discussion 940-1. PMID: 24112675
  4. NEJM Knowledge+ Gastroenterology