Review Question - QID 104821

This patient is presenting with acute acalculous cholecystitis. Acute acalculous cholecystitis is the acute inflammation of the gallbladder in the absence of gallstones, often observed in very ill patients with sepsis, trauma, or severe burns.

Acute acalculous cholecystitis can complicate severe illness or major trauma and surgery. It is defined as inflammation of the gallbladder without evidence of gallstones. It is thought to be caused by bile stasis which occurs in severe illness due to lack of oral intake. Acute acalculous cholecystitis is very dangerous and carries a mortality rate of approximately 30%, most likely due its ability to progress rapidly to perforation and gangrene. Diagnosis is challenging as most patients are already very ill and often cannot communicate effectively. However, commonly observed findings are fever, elevated WBC, and right sided abdominal pain. Diagnosis is usually made by ultrasound which shows gallbladder inflammation without evidence of gallstones. Treatment is immediate cholecystectomy if patients can tolerate surgery or percutaneous drainage via cholecystostomy.

Treinen et al. review the risk factors and surgical treatment options for patients with acute acalculous cholecystitis. They state that acute acalculous cholecystitis is characterized by severe gallbladder inflammation without cystic duct obstruction. They find that patients that are healthy enough to tolerate laparoscopic cholecystectomy should undergo laparoscopic cholecystectomy early in the course of the disease. In critically ill patients, patients with multiple comorbidities, or who are poor surgical candidates, percutaneous cholecystostomy may be the safest and most successful intervention.

Kirkegård et al. examine the effectiveness of percutaneous cholecystostomy as definitive treatment for acute acalculous cholecystitis. They perform an observation study and find percutaneous cholecystostomy to be successful as a definitive treatment option in the majority of patients with acute acalculous cholecystitis. It was associated with a low rate of mortality and subsequent cholecystectomy.

Figure A is a chest radiograph demonstrating a lobar pneumonia, the cause of severe sepsis in this patient. Figure B demonstrates the ultrasound findings observed in acute acalculous cholecystitis. Note the gallbladder wall thickening without evidence of gallstone. Illustration A is a diagram demonstrating the pathogenesis of acute acalculous cholecystitis. Illustration B is a gross specimen of a gangrenous gallbladder resulting from acute acalculous cholecystitis.

Incorrect answers:
Answer 1: Cholelithiasis (gallstones) typically present as biliary colic, sharp RUQ pain following large meals. This is not consistent with this patient's severe presentation.
Answer 2: Cholangitis is characterized by Charcot's triad of jaundice, fever, and RUQ pain. While this patient has fever and RUQ pain, he is not jaundiced as would be expected in cholangitis.
Answer 3: Acute calculous cholecystitis would be expected to demonstrate gallstones on ultrasound.
Answer 5: This patient's amylase and lipase are normal making acute pancreatitis unlikely.