Acute acalculous cholecystitis

Abstract

Acute cholecystitis can develop without gallstones in critically ill or injured patients. However, the development of acute acalculous cholecystitis is not limited to surgical or injured patients, or even to the intensive care unit. Diabetes, malignant disease, abdominal vasculitis, congestive heart failure, cholesterol embolization, and shock or cardiac arrest have been associated with acute acalculous cholecystitis. Children may also be affected, especially after a viral illness. The pathogenesis of acute acalculous cholecystitis is a paradigm of complexity. Ischemia and reperfusion injury, or the effects of eicosanoid proinflammatory mediators, appear to be the central mechanisms, but bile stasis, opioid therapy, positive-pressure ventilation, and total parenteral nutrition have all been implicated. Ultrasound of the gallbladder is the most accurate diagnostic modality in the critically ill patient, with gallbladder wall thickness of 3.5 mm or greater and pericholecystic fluid being the two most reliable criteria. The historical treatment of choice for acute acalculous cholecystitis has been cholecystectomy, but percutaneous cholecystostomy is now the mainstay of therapy, controlling the disease in about 85% of patients. Rapid improvement can be expected when the procedure is performed properly. The mortality rates (historically about 30%) for percutaneous and open cholecystostomy appear to be similar, reflecting the severity of illness, but improved resuscitation and critical care may portend a decreased risk of death. Interval cholecystectomy is usually not indicated after acute acalculous cholecystitis in survivors; if the absence of gallstones is confirmed and the precipitating disorder has been controlled, the cholecystostomy tube can be pulled out after the patient has recovered.

Tempol protects the gallbladder against ischemia/reperfusion

“…nutrition, or sepsis [2], but de novo presentation in the absence of critical illness or predisposing factors has also been reported. AC is believed to have a more fulminant course, as well as significantly higher morbidity and mortality than gallstone-associated acute cholecystitis [15].…”

Acute acalculous cholecystitis of viral etiology—a rare condition in children?

“…It comprises 5% to 10% of all cases of acute cholecystitis in adults and appears to be even less frequently diagnosed in children [1][2][3][4]. Acute acalculous cholecystitis may be observed in the course of some critical diseases such as sepsis, trauma, and burns; in Salmonella or Giardia lamblia infections; or in systemic diseases (lupus erythematosus, periarteritis) [1,2]. Acute cholecystitis owing to viral infectious factors is reported to be extremely rare in the medical literature [4,5].…”

A rare case of primary EBV infection causing acute acalculous cholecystitis

“…The exact etiology of AAC remains unclear, but it is believed that conditions including severe trauma, burns, cardiovascular disease, major surgeries, and long term TPN lead to stasis, ischemia, and resultant inflammation of the gallbladder. In children however, AAC accounts for 30e50% of cholecystitis cases and is more commonly associated with congenital biliary anomalies; infectious diseases such as viral hepatitis, primary EBV and CMV infections, leptospirosis, Typhoid fever, Q-fever, Candida, and parasitic infections; and systemic disease such as Kawasaki disease [4].…”