Acalculous cholecystitis in critically III patients

Abstract

Acute acalculous cholecystitis is a treacherous and potentially fatal complication of severe trauma and prolonged intensive care. The present study reviews seventeen patients seen between June 1974 and August 1977. Although specific causes have been suggested—transfusions, fractures with immobilization, central hyperalimentation, respirators, and “refeeding”—there was no common denominator among our patients. Refeeding was a feature in 30 per cent of our cases, 50 per cent received more than 10 units of blood, 65 per cent had prolonged gastric suction, and 60 per cent had mechanical ventilation. Thus, although all suggested causes were seen, no single factor was dominant. Clinical presentation in this civilian group resembles that of other reports, but differs in remarkable areas. Only 65 per cent of our group presented with one or more of the classic symptoms of cholecystitis—pain, tenderness, or mass. Sixty-five per cent of patients had elevated bilirubin levels. However, the same incidence of hyperbilirubinemia was seen in another group of traumatized patients who did not develop acalculous cholecystitis. The smoldering and nonclassic presentation frequently delayed diagnosis for several days. It was correctly made in 65 per cent, discovered at autopsy in one patient, and found at laparotomy for “sepsis” in the rest. The present report is unique because 88 per cent of the patients had cholecystostomy as initial therapy. Although five patients who underwent operation ultimately succumbed, cholecystitis could be implicated in only one. This patient died of sepsis at 24 hours but also had multiple unrelated intraabdominal abscesses at surgery. Clinical presentation is more complex than previously reported and simple cholecystostomy is an effective mode of therapy in these critically ill patients.