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eMedicine Specialties > Gastroenterology > Biliary

Acalculous Cholecystitis

Homayoun Shojamanesh, MD, Former Fellow, Digestive Diseases Branch, National Institutes of Health
Praveen K Roy, MD, Comments and Criticisms Editor, Cochrane Colorectal Cancer Group

Updated: Aug 27, 2009

Introduction

Background

Acalculous cholecystitis is a severe illness that is a complication of various other medical or surgical conditions. Duncan first recognized it in 1844 when a fatal case of acalculous cholecystitis complicating an incarcerated hernia was reported. The condition causes approximately 5-10% of all cases of acute cholecystitis and is usually associated with more serious morbidity and higher mortality rates than calculous cholecystitis. It is most commonly observed in the setting of very ill patients (eg, on mechanical ventilation, with sepsis or severe burn injuries,1 after severe trauma2 ). In addition, acalculous cholecystitis is associated with a higher incidence of gangrene and perforation compared to calculous disease.

The usual finding on imaging studies is a distended acalculous gallbladder with thickened walls (>3-4 mm) with or without pericholecystic fluid. Acalculous cholecystitis can be observed in patients with human immunodeficiency virus (HIV) infection, although it is a late manifestation of this disease. Acalculous cholecystitis can also be found in patients on total parenteral nutrition (TPN), typically those on TPN for more than 3 months.

Pathophysiology

The main cause of this illness is thought to be due to bile stasis and increased lithogenicity of bile. Critically ill patients are more predisposed because of increased bile viscosity due to fever and dehydration and because of prolonged absence of oral feeding resulting in a decrease or absence of cholecystokinin-induced gallbladder contraction. Gallbladder wall ischemia that occurs because of a low-flow state due to fever, dehydration, or heart failure may also play a role in the pathogenesis of acalculous cholecystitis.

Frequency

United States

Acalculous cholecystitis comprises approximately 5-10% of all cases of acute cholecystitis.

Mortality/Morbidity

The mortality and morbidity rates associated with acalculous cholecystitis can be high; the illness is frequently observed in patients with sepsis or other serious conditions. The reported mortality range is 10-50% for acalculous cholecystitis as compared to 1% for calculous cholecystitis.

Race

It can occur in all races.

Sex

Acalculous cholecystitis has a slight male predominance, unlike calculous cholecystitis, which has a female predominance.

Age

The condition can occur in persons of any age, although a higher frequency is reported in persons in their fourth and eighth decades of life.

Clinical

History

History findings are of limited value. Often, many patients are very ill (possibly on mechanical ventilation) and cannot communicate a history or symptoms.

Physical

Physical examination may reveal fever and right upper quadrant tenderness.

Causes

The main cause of acalculous cholecystitis is gallbladder stasis with resulting stagnant bile. This is observed most commonly in patients with sepsis, patients in intensive care units, patients on long-term TPN, patients with diabetes (occasionally), or other patients with gallbladder dysmotility. The condition has also been reported during pregnancy, as a complication of hepatitis A.3  It has been rarely reported in children, also as a complication of hepatitis A,4 with a favorable course with conservative treatment.

Differential Diagnoses

Other Problems to Be Considered

Sepsis with biliary tract infection
AIDS cholangiopathy
TPN-associated liver disease

Workup

Laboratory Studies

  • CBC count, liver function tests, and blood culture tests are some of the main laboratory tests that should be performed. Bile culture results are negative in nearly 50% of patients with acalculous cholecystitis, probably because of concurrent antibiotic therapy in these patients.

Imaging Studies

  • Perform ultrasound or computed tomography (CT) scanning of the abdomen.

Procedures

  • For surgical candidates, perform cholecystectomy using an open or laparoscopic approach as indicated.
  • For patients who are not surgical candidates, perform percutaneous cholecystostomy.

Treatment

Medical Care

When the diagnosis of acalculous cholecystitis is established, immediate intervention is indicated because of the high risk of rapid deterioration and gallbladder perforation.

In patients with acalculous cholecystitis who are high-risk surgical candidates (ie, end-stage liver disease), endoscopic gallbladder stent placement has been reported as an effective palliative treatment. This involves placement of a double pigtail stent between the gallbladder and the duodenum during endoscopic retrograde cholangiopancreatography (ERCP). However, the definitive treatment of acalculous cholecystitis is cholecystectomy for patients who are able to tolerate surgery.

Surgical Care

In surgical candidates, open or laparoscopic cholecystectomy is indicated.5 In patients who are not surgical candidates, percutaneous cholecystostomy may be performed in the radiology suite. Catheters are usually removed after approximately 3 weeks in critically ill patients with acalculous cholecystitis who have undergone percutaneous cholecystostomy. This allows for the development of a mature track from the skin to the gallbladder.

Consultations

  • Gastroenterologists
  • Surgeons
  • Radiologists

Diet

Patients in the acute stage of acalculous cholecystitis should receive nothing by mouth. Hydration with intravenous fluids should be provided.

Medication

Administer broad-spectrum antibiotics for enteric and biliary pathogen coverage. Definitive treatment is cholecystectomy in patients who are surgical candidates or cholecystostomy in patients who are not surgical candidates.

Follow-up

Complications

  • Perforation or gangrene of the gallbladder and extrabiliary abscess formation may occur.

Prognosis

  • Prognosis is guarded.

Miscellaneous

Medicolegal Pitfalls

  • Delay in diagnosis or treatment may result in higher mortality rates.

References

  1. Theodorou P, Maurer CA, Spanholtz TA, Phan TQ, Amini P, Perbix W, et al. Acalculous cholecystitis in severely burned patients: incidence and predisposing factors. Burns. May 2009;35(3):405-11. [Medline].

  2. Hamp T, Fridrich P, Mauritz W, Hamid L, Pelinka LE. Cholecystitis after trauma. J Trauma. Feb 2009;66(2):400-6. [Medline].

  3. Basar O, Kisacik B, Bozdogan E, et al. An unusual cause of acalculous cholecystitis during pregnancy: hepatitis A virus. Dig Dis Sci. Aug 2005;50(8):1532. [Medline].

  4. Fuoti M, Pinotti M, Miceli V, et al. [Acute acalculous cholecystitis as a complication of hepatitis A: report of 2 pediatric cases] [Italian]. Pediatr Med Chir. Mar-Apr 2008;30(2):102-5. [Medline].

  5. Casillas RA, Yegiyants S, Collins JC. Early laparoscopic cholecystectomy is the preferred management of acute cholecystitis. Arch Surg. Jun 2008;143(6):533-7. [Medline].

  6. Babb RR. Acute acalculous cholecystitis. A review. J Clin Gastroenterol. Oct 1992;15(3):238-41. [Medline].

  7. Barie PS, Fischer E. Acute acalculous cholecystitis. J Am Coll Surg. Feb 1995;180(2):232-44. [Medline].

  8. Boland G, Lee MJ, Mueller PR. Acute cholecystitis in the intensive care unit. New Horiz. May 1993;1(2):246-60. [Medline].

  9. Boland GW, Lee MJ, Dawson SL, Mueller PR. Percutaneous cholecystostomy for acute acalculous cholecystitis in a critically ill patient. AJR Am J Roentgenol. Apr 1993;160(4):871-4. [Medline].

  10. Chung SC. Acute acalculous cholecystitis. A reminder that this condition may appear in a primary care practice. Postgrad Med. Sep 1995;98(3):199-200, 203-4. [Medline].

  11. Conway JD, Russo MW, Shrestha R. Endoscopic stent insertion into the gallbladder for symptomatic gallbladder disease in patients with end-stage liver disease. Gastrointest Endosc. Jan 2005;61(1):32-6. [Medline].

  12. Fisher RL. Hepatobiliary abnormalities associated with total parenteral nutrition. Gastroenterol Clin North Am. Sep 1989;18(3):645-66. [Medline].

  13. Hasse C, Zielke A, Nies C, et al. Influence of ceruletid on gallbladder contraction: a possible prophylaxis of acute acalculous cholecystitis in intensive care patients?. Digestion. 1995;56(5):389-94. [Medline].

  14. Hatada T, Kobayashi H, Tanigawa A, et al. Acute acalculous cholecystitis in a patient on total parenteral nutrition: case report and review of the Japanese literature. Hepatogastroenterology. Jul-Aug 1999;46(28):2208-11. [Medline].

  15. Kageoka M, Watanabe F, Maruyama Y, et al. Long-term prognosis of patients after endoscopic sphincterotomy for choledocholithiasis. Dig Endosc. Jul 2009;21(3):170-5. [Medline].

  16. Lameris JS, van Overhagen H. Imaging and intervention in patients with acute right upper quadrant disease. Baillieres Clin Gastroenterol. Mar 1995;9(1):21-36. [Medline].

  17. Lee SW, Yang SS, Chang CS, Yeh HJ. Impact of the Tokyo guidelines on the management of patients with acute calculous cholecystitis. J Gastroenterol Hepatol. Aug 3 2009;epub ahead of print. [Medline].

  18. Lillemoe KD. Surgical treatment of biliary tract infections. Am Surg. Feb 2000;66(2):138-44. [Medline].

  19. Merrell RC, Miller-Crotchett P, Lowry P. Gallbladder response to enteral lipids in injured patients. Arch Surg. Mar 1989;124(3):301-2. [Medline].

  20. Nash JA, Cohen SA. Gallbladder and biliary tract disease in AIDS. Gastroenterol Clin North Am. Jun 1997;26(2):323-35. [Medline].

  21. Owen CC, Bilhartz LE. Gallbladder polyps, cholesterolosis, adenomyomatosis, and acute acalculous cholecystitis. Semin Gastrointest Dis. Oct 2003;14(4):178-88. [Medline].

  22. Schwesinger WH, Diehl AK. Changing indications for laparoscopic cholecystectomy. Stones without symptoms and symptoms without stones. Surg Clin North Am. Jun 1996;76(3):493-504. [Medline].

Keywords

acalculous cholecystitis, acute cholecystitis, cholecystitis, gallbladder inflammation, inflammation of the gallbladder, gallbladder pain, total parenteral nutrition, TPN, bile stasis, gallbladder stasis, stagnant bile, gallbladder dysmotility, sepsis with biliary tract infection, AIDS cholangiopathy, TPN-associated liver disease, cholecystectomy, percutaneous cholecystostomy

Contributor Information and Disclosures

Author

Homayoun Shojamanesh, MD, Former Fellow, Digestive Diseases Branch, National Institutes of Health
Homayoun Shojamanesh, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Coauthor(s)

Praveen K Roy, MD, Comments and Criticisms Editor, Cochrane Colorectal Cancer Group
Praveen K Roy, MD is a member of the following medical societies: American College of Gastroenterology, American Gastroenterological Association, and Canadian Association of Gastroenterology
Disclosure: Nothing to disclose.

Medical Editor

Marco G Patti, MD, Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine
Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Surgical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael A Grosso, MD, Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital
Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

Further Reading

Related eMedicine Topics

  • Acalculous Cholecystopathy 
  • Cholecystitis [in the Gastroenterology section]
  • Cholecystitis [in the Pediatrics: General Medicine section]
  • Cholecystitis, Acalculous [in the Radiology section]
  • Cholecystitis, Acute [in the Radiology section]
  • Cholelithiasis [in the Gastroenterology section]
  • Cholelithiasis [in the Radiology section]
Clinical Trials
  • Acute Cholecystitis – Early Laparoscopic Surgery Versus Antibiotic Therapy and Delayed Elective Cholecystectomy (ACDC)
  • Harmonic in Laparoscopic Cholecystectomy for Acute Cholecystitis (HAC)
  • NOTES-Assisted Laparoscopic Cholecystectomy Surgery
  • Single Port Access (SPA) Cholecystectomy Versus Standard Laparoscopic Cholecystectomy Study of Pain Perception Between Males and Females Following Laparoscopic Cholecystectomy
National Guideline Clearinghouse
  • ACR Appropriateness Criteria® acute abdominal pain and fever or suspected abdominal abscess. American College of Radiology - Medical Specialty Society. 1996 (revised 2006). 7 pages. NGC:005138
  • ACR Appropriateness Criteria® right upper quadrant pain. American College of Radiology - Medical Specialty Society. 1996 (revised 2007). 5 pages. NGC:006992
  • Diagnostic laparoscopy for acute abdominal pain. In: Diagnostic laparoscopy guidelines. Society of American Gastrointestinal and Endoscopic Surgeons - Medical Specialty Society. 1998 Apr (revised 2007 Nov). 7 pages. NGC:006830

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