ACUTE ACALCULOUS CHOLECYSTITIS: Author's reply

Abstract

This refers to the case report "Acute Acalculous cholecystitis" by Lt Col DJ Singh recently published in MJAFI [1], Clinical and ultrasonographic evidence of gall bladder involvement has also been reported in acute viral hepatitis (AVH) (2j. Involvement of gall bladder wall (GBW) by the virus has been postulated as the most plausible explanation for the GBW thickening in AVH [3].The other possible mochanisms suggested are hypoalbuminemia, lymphatic obstruction, reduced bile flow, and involvement of GBW in the immuno-inflammatory process occurring in adjacent liver tissue. We had studied GBW thickness in 118 consecutive patients of AVH and compared this with their clinical and biochemical profile during 1st to 4th week of illness [21. Significant thickening of GWB was observed in 77% of patients. A statistically significant correlation was seen with non-A, Non-B hepatitis (NANB). Within NANB group, comprising 83 patients. GBW thickening was again significantly more pronounced (P = < .001) in those 20 patients who had presented with right upper quadrant pain, fever and a positive ultrasonographic Murphy's sign, a presentation like acute cholecystitis -similar to cases No. 2 and 3 of the authors [1].These observations warrant a careful evaluation of all patients of acute acalculous cholecystitis (AAC) for presence of AVH since surgery in AVH can prove hazardous. Rightly so, the author's patients were managed conservatively and improved. He has not mentioned the levels of liver enzymes (SGOT, SGPT) in his report. These are usually raised in AAC associated with AVH. A study of viral markers for hepatitis B, hepatitis C, and hepatitis Ε virus (HBV, HCV and HEV respectively) may also help in establishing the diagnosis.The question which still remains unanswered is that which of the currently known Non-Α, Non-B viruses (HCV, HEV hepatitis G virus or hepatitis H virus) are likely to predominantly attack gall bladder producing an acute cholecystitis like picture? Our own unpublished experience so far suggests that it is at least not the HCV. lt could possibly be HEV or another non-Α, non-B virus.