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.
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, 12] 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 postprocedure period.
Anderson et al reported that cholecystostomy offered no survival benefit for patients with severe sepsis and shock; however, cholecystostomy was associated with improved survival compared with patients without surgical management.
Treinen C, Lomelin D, Krause C, Goede M, Oleynikov D. Acute acalculous cholecystitis in the critically ill: risk factors and surgical strategies. Langenbecks Arch Surg. 2015 May. 400(4):421-7. [Medline].
Tana M, Tana C, Cocco G, Iannetti G, Romano M, Schiavone C. Acute acalculous cholecystitis and cardiovascular disease: a land of confusion. J Ultrasound. 2015 Dec. 18(4):317-20. [Medline].
Theodorou P, Maurer CA, Spanholtz TA, et al. Acalculous cholecystitis in severely burned patients: incidence and predisposing factors. Burns. 2009 May. 35(3):405-11. [Medline].
Hamp T, Fridrich P, Mauritz W, Hamid L, Pelinka LE. Cholecystitis after trauma. J Trauma. 2009 Feb. 66(2):400-6. [Medline].
Basar O, Kisacik B, Bozdogan E, et al. An unusual cause of acalculous cholecystitis during pregnancy: hepatitis A virus. Dig Dis Sci. 2005 Aug. 50(8):1532. [Medline].
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. 2008 Mar-Apr. 30(2):102-5. [Medline].
Gu MG, Kim TN, Song J, Nam YJ, Lee JY, Park JS. Risk factors and therapeutic outcomes of acute acalculous cholecystitis. Digestion. 2014. 90(2):75-80. [Medline].
Joseph T, Unver K, Hwang GL, et al. Percutaneous cholecystostomy for acute cholecystitis: ten-year experience. J Vasc Interv Radiol. 2012 Jan. 23(1):83-8.e1. [Medline].
Chung YH, Choi ER, Kim KM, et al. Can percutaneous cholecystostomy be a definitive management for acute acalculous cholecystitis?. J Clin Gastroenterol. 2012 Mar. 46(3):216-9. [Medline].
Irani S, Baron TH, Grimm IS, Khashab MA. EUS-guided gallbladder drainage with a lumen-apposing metal stent (with video). Gastrointest Endosc. 2015 Dec. 82(6):1110-5. [Medline].
Casillas RA, Yegiyants S, Collins JC. Early laparoscopic cholecystectomy is the preferred management of acute cholecystitis. Arch Surg. 2008 Jun. 143(6):533-7. [Medline].
Schuld J, Glanemann M. Acute cholecystitis. Viszeralmedizin. 2015 Jun. 31(3):163-5. [Medline].
Kirkegard J, Horn T, Christensen SD, Larsen LP, Knudsen AR, Mortensen FV. Percutaneous cholecystostomy is an effective definitive treatment option for acute acalculous cholecystitis. Scand J Surg. 2015 Dec. 104(4):238-43. [Medline].
Anderson JE, Inui T, Talamini MA, Chang DC. Cholecystostomy offers no survival benefit in patients with acute acalculous cholecystitis and severe sepsis and shock. J Surg Res. 2014 Aug. 190(2):517-21. [Medline].