Wednesday, May 10, 2017

Acalculous cholecystitis notes


Let's learn about Acalculous cholecystitis today. These are my step 2 CK notes, made from UpToDate.

What is acalculous cholecystitis?

Acalculous cholecystitis is an acute necroinflammatory disease of the gallbladder with a multifactorial pathogenesis. It is typically seen in patients who are hospitalized and critically ill.

Clinical features:
In critically ill patients, the appearance of unexplained fever, leukocytosis, or vague abdominal discomfort may be the only sign of acalculous cholecystitis. Patients may also have jaundice or a right upper quadrant mass. Laboratory test abnormalities may include a leukocytosis or abnormal liver tests, but they are nonspecific.

Diagnosis: USG.

Advantages of ultrasonography are that it is noninvasive, can be done at the bedside, and has good sensitivity and specificity for diagnosing acalculous cholecystitis. In addition, ultrasonography may reveal alternative diagnoses (such as calculous cholecystitis). Thickening of the gallbladder wall is the most reliable feature seen in patients with acalculous cholecystitis.

Ultrasonographic features:
●Absence of gallstones or sludge
●Thickening of the gallbladder wall (>3 mm)
●Pericholecystic fluid
●Striated gallbladder
●A positive Murphy's sign induced by the ultrasound probe (may be absent in patients who are obtunded or sedated)
●Mucosal sloughing
●Gallbladder distension (>5 cm).

In patients with acalculous cholecystitis, we recommend the initiation of broad spectrum antibiotics as soon as blood cultures have been drawn.

Infection with enteric pathogens, including E. coli, E. faecalis, Klebsiella, Pseudomonas, Proteus species, and Bacteroides is common.

Preferred surgery: Cholecystostomy rather than cholecystectomy.


Cholecystostomy is effective and is less invasive than cholecystectomy. (especially in critically ill patients.)

However, cholecystectomy should be performed if there are findings suggesting gallbladder necrosis, emphysematous cholecystitis, or perforation. Cholecystectomy is also a reasonable alternative in patients who are good surgical candidates.

That's all!

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