Presentation on Acalculous Cholecystitis

Introduction

• Acalculous cholecystitis is discussed due to its high mortality rate in critically ill patients.
• Mortality can be as high as 50%, indicating the seriousness of the condition.

Definition

• Acalculous Cholecystitis: Acute life-threatening necro-inflammatory disorder of the gallbladder, usually seen in critically ill patients. Important to note, it's not associated with gallstones.

Mortality

• In acute cholecystitis with gallstones, mortality is around 0.1% to 3%.
• In acalculous cholecystitis, mortality can reach up to 50%.

Epidemiology

• More common in males, contrary to acute cholecystitis, which is more common in females.

Etiology

• Common in ICU patients and post-surgery, especially heart surgery.
• Associated with conditions like sepsis, septic shock, prolonged fasting (e.g., intermittent fasting), TPN, infections, and immunodeficiency.

Clinical Features

• Right Upper Quadrant Pain: Present in only 25% of acalculous cholecystitis cases.
• Other features: fever, nausea, vomiting, Murphy's sign. Note that Murphy's sign is often not observed due to patient conditions (e.g., unconsciousness).

Pathophysiology

• Conditions like shock, substance abuse, heart failure, hemorrhage can compromise blood circulation, leading to gallbladder ischemia.
• Gallbladder wall thickening (>4mm), loss of mucosal integrity, bacterial invasion (common bacteria: E. coli).
• Intermittent fasting or dehydration may increase bile viscosity, leading to inflammation and necrosis of the gallbladder.

Diagnosis

• Lab Tests: Look for increased amylase levels without an increase in lipase (no pancreatitis).
• Ultrasound: Primary diagnostic tool; looks for gallbladder wall thickening (>4mm) and pericholecystic fluid.
• HIDA Scan: Used to evaluate gallbladder; cholecystokinin is given to stimulate gallbladder contractions.

Treatment

• Initial Management: NPO (nothing by mouth), IV fluids, analgesics, and IV antibiotics (e.g., Imipenem or Meropenem for severe cases).
• Surgical Intervention: Laparoscopic cholecystectomy if possible.
• For High-Risk Patients: Percutaneous cholecystostomy tube placement.

Complications

• Gangrene, perforation, abscess formation, prolonged ICU stay.

Key Points

• Acalculous cholecystitis is a critical condition with high mortality.
• Often lacks classic symptoms like right upper quadrant pain.
• Requires prompt diagnosis and treatment due to high risk of complications.

Conclusion

• The condition is serious, especially in critically ill patients, and requires vigilance in diagnosis and management.

Note: Always consider blood circulation status and imaging findings in diagnosis.