Outline  the clinical manifestations, appropriate investigations, and treatment of acalculous  cholecystitis.

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College Answer

Clinical presentation is variable and all signs and investigations lack sensitivity and specificity. Symptoms/signs include fever, leukocytosis with a left shift, abdominal pain, right upper quadrant mass, hyperbilirubinaemia, increased alkaline phosphatase and serum transaminases.

Additional investigations (assuming full blood count and liver function tests have already been performed) should include: ultrasonography (may be diagnostic) +/- CT abdomen and blood cultures. HIDA scans are reported to be useful in cases when diagnoses can’t be established with certainty.

Treatment involves broad spectrum antibiotics, though the definitive treatment is drainage. Percutaneous drainage (via ultrasound guidance) may be performed if the patient is too sick to transport, otherwise invasive techniques (laparoscopic or open) may be considered.

Discussion

Acalculous cholecystitis receives a detailed treatment elsewhere.

Clinical manifestations:

  • RUQ pain
  • High bilirubin
  • Cholestatic pattern of LFT elevation
  • Fever
  • Bacteraemia
  • Sympathetic right sided pleural effusion
  • Haemodynamic instability

Diagnostic investigations

  • Abdominal ultrasound
  • Abdominal CT
  • HIDA
  • Blood cultures
Options for Management of Acalculous Cholecystitis

Option

Advantages

Disadvantages
Conservative (antibiotics)
  • Few complications
  • May be the only option for high risk patients.
  • In a mixed (calculous and acalculous) group, 87% of conservatively managed patients recovered completely.
  • Patients with reasonably normal gall bladder function (over 40% GBEF) only need conservative management.
  • There is still an option to progress to one of the other treatment options.
  • May delay definitive treatment
  • The gallbladder may become necrotic and rupture, causing peritonitis
  • Patients with a severely infected gall bladder will continue to get worse, as source control has not been achieved.
Percutaneous cholecystostomy
Laparoscopic cholecystectomy
  • Fewer complications than open cholecystectomy
  • A definitive management option
  • Not an option in some patients, particularly morbidly obese patients and those with severe respiratory failure
  • Requires a surgeon familiar with the approach
  • May end up converting to open anyway, losing all benefits of the laparoscopic approach.
Open cholecystectomy
  • A definitive management option.
  • Allows for a thorough washout.
  • Accomodates weird anatomy and allows earlier maagement of surgical complications.
  • May be the only option for those with a gangrenous or perforated gall bladder.
  • Significant morbidity post operatively in the critically ill population (mortality may be up to 19%)

References

Laurila, Jouko, et al. "Acute acalculous cholecystitis in critically ill patients."Acta anaesthesiologica scandinavica 48.8 (2004): 986-991.

Wang, Ay-Jiun, et al. "Clinical predictors of severe gallbladder complications in acute acalculous cholecystitis." Heart 1500 (2003): 8.

Boland, Giles W., et al. "Percutaneous cholecystostomy in critically ill patients: early response and final outcome in 82 patients." American Journal of Roentgenology 163.2 (1994): 339-342.