Acalculous Cholecystitis: Diagnosis and Treatment

Abstract

Acute acalculous cholecystitis (AAC) traditionally occurs in critically ill patients with chronic debilitating diseases, those with superimposed critical illness, trauma, or major burns. Ultrasonography (US), computed tomography (CT), and a hepatobiliary iminodiacetic acid (HIDA) scan are diagnostic imaging modalities used in patients with a high index of clinical suspicion during the early stage of AAC. Diagnostic criteria for AAC using US/CT include gallbladder (GB) wall thickness ≥3.5 mm, pericholecystic fluid or subserosal edema, intramural gas, coarse mucosa, sludge, and hydrops. The most common indication for a HIDA scan is acute cholecystitis diagnosed by nonvisualization of the GB secondary to cystic duct obstruction. Cholecystectomy is the mainstay of treatment for AAC, particularly in patients with suspected perforation or gangrene. Several studies report that percutaneous cholecystostomy not only serves as a bridge for cholecystectomy but can also definitively treat AAC, particularly in high-risk surgical patients. Endoscopically placed lumen-apposing metal stents are useful for safe and effective transmural GB drainage in patients with AAC. Early diagnosis and prompt treatment are essential to avoid a fulminant course and complications, such as gangrene or perforation associated with high mortality rates.