Acalculous Cholecystitis Treatment & Management
- Author: Homayoun Shojamanesh, MD; Chief Editor: John Geibel, MD, DSc, MSc, AGAF more...
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), Gu et al reported that endoscopic gallbladder stent placement 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.
However, in selected patients with acute acalculous cholecystitis (AAC), nonsurgical treatment (such as antibiotics or percutaneous cholecystostomy) may be an effective alternative to surgery. In the study by Gu et al, data from 69 patients with AAC was compared with those from 415 patients with acute calculous cholecystitis (ACC). The investigators found that among those patients who underwent nonsurgical therapy, the posttreatment recurrence rate was just 2.7% in the AAC group, compared with 23.2% in the ACC patients.
In a retrospective study of 15 nonsurgical patients who underwent endoscopic ultrasonography-guided transmural gallbladder drainage (EUS-GBD) with a lumen-apposing metal stent (LAMS) for different biliary conditions including 4 cases of acalculous cholecystitis, technical success was achieved in 14 of the 15 patients (93%), with clinical success in all 15 patients (median follow-up, 160 days).
Consult with the following specialists:
Patients in the acute stage of acalculous cholecystitis should receive nothing by mouth. Hydration with intravenous fluids should be provided.
In surgical candidates, open or laparoscopic cholecystectomy is indicated for acute cholecystitis.[1, 11] Laparoscopic cholecystectomy performed within 24 hours of inpatient admission has been reported to be safe and is recommended as the preferred treatment option for those with American Society of Anesthesiologists (ASA) grade I-III disease.
In patients who are not surgical candidates, percutaneous cholecystostomy may be performed in the radiology suite. This procedure may the safest and most successful intervention in patients who are critically ill, have multiple comorbidities, have a high risk for conversion, or who are poor surgical candidates. 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.
In an observational study (2002-2012) of 56 patients treated with percutaneous cholecystostomy for acute acalculous cholecystitis, Kirkegard et al found the procedure could be used as a definitive treatment option in 45 patients (80.4%) and as a bridge to elective laparoscopic cholecystectomy in 4 patients (7.1%) within a median of 8.8 months. Six patients (10.7%) died within the 30-day postpartum period.
Note that cholecystostomy appears to offer no survival benefit for patients with severe sepsis and shock, but it may provide an improved survival compared with patients without surgical management.
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