Acalculous Cholecystitis: Background, Pathophysiology, Etiology (original) (raw)

Overview

Background

Acalculous cholecystitis is an inflammatory disease of the gallbladder without evidence of gallstones or cystic duct obstruction [1, 2] ; it 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, [3] after severe trauma [4] ). 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 three months.

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Pathophysiology

The main cause of this illness is thought to be 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.

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Etiology

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 total parenteral nutrition (TPN), those with cardiovascular disease, [2] patients with diabetes (occasionally), or other patients with gallbladder dysmotility. The condition has been reported during pregnancy, as a complication of hepatitis A. [5] It has been rarely reported in children, also as a complication of hepatitis A, [6] with a favorable course with conservative treatment. This disease has also been reported as associated with aortic dissection. [7]

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Epidemiology

United States statistics

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

Race-, sex-, age-related demographics

It can occur in all races.

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

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.

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Prognosis

The prognosis of patients with acalculous cholecystitis is guarded.

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.

A study by Gu et al found a significantly higher frequency of cerebrovascular accidents in patients with acute acalculous cholecystitis (AAC) than those with acute calculous cholecystitis (ACC), the respective rates being 15.9% and 6.7%. The incidence of gangrenous cholecystitis was also greater in the AAC than in ACC (31.2% vs 5.6%, respectively). [8]

Complications

Perforation or gangrene of the gallbladder and extrabiliary abscess formation may occur. [9]

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  1. 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. [QxMD MEDLINE Link].
  2. 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. [QxMD MEDLINE Link].
  3. 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. [QxMD MEDLINE Link].
  4. Hamp T, Fridrich P, Mauritz W, Hamid L, Pelinka LE. Cholecystitis after trauma. J Trauma. 2009 Feb. 66(2):400-6. [QxMD MEDLINE Link].
  5. 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. [QxMD MEDLINE Link].
  6. 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. [QxMD MEDLINE Link].
  7. Inagaki FF, Hara Y, Kamei M, Tanaka M, Yasuno M. Acute and chronic acalculous cholecystitis associated with aortic dissection. J Surg Case Rep. 2015 Aug 1. 2015(8):[QxMD MEDLINE Link]. [Full Text].
  8. 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. [QxMD MEDLINE Link].
  9. Wood BE, Trautman J, Smith N, Putnis S. Rare case report of acalculous cholecystitis: Gallbladder torsion resulting in rupture. SAGE Open Med Case Rep. 2019. 7:2050313X18823385. [QxMD MEDLINE Link]. [Full Text].
  10. 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. [QxMD MEDLINE Link].
  11. 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. [QxMD MEDLINE Link].
  12. Noh SY, Gwon DI, Ko GY, Yoon HK, Sung KB. Role of percutaneous cholecystostomy for acute acalculous cholecystitis: clinical outcomes of 271 patients. Eur Radiol. 2018 Apr. 28(4):1449-55. [QxMD MEDLINE Link].
  13. Soria Aledo V, Galindo Iniguez L, Flores Funes D, Carrasco Prats M, Aguayo Albasini JL. Is cholecystectomy the treatment of choice for acute acalculous cholecystitis? A systematic review of the literature. Rev Esp Enferm Dig. 2017 Oct. 109(10):708-18. [QxMD MEDLINE Link]. [Full Text].
  14. 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. [QxMD MEDLINE Link].
  15. 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. [QxMD MEDLINE Link].
  16. Casillas RA, Yegiyants S, Collins JC. Early laparoscopic cholecystectomy is the preferred management of acute cholecystitis. Arch Surg. 2008 Jun. 143(6):533-7. [QxMD MEDLINE Link].
  17. Schuld J, Glanemann M. Acute cholecystitis. Viszeralmedizin. 2015 Jun. 31(3):163-5. [QxMD MEDLINE Link].
  18. 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. [QxMD MEDLINE Link].
  19. Jones MW, Ferguson T. Acalculous cholecystitis. StatPearls [Internet]. 2019 Jan 16. 2018:[QxMD MEDLINE Link]. [Full Text].

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Author

Coauthor(s)

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF 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, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Marco G Patti, MD Surgeon, UNC Hospitals Multispecialty Surgery Clinic

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, Western Surgical Association

Disclosure: Nothing to disclose.

Acknowledgements

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.