Acalculous Cholecystitis

Created on Mon, 07/13/2015 - 19:38
Last updated on Thu, 08/27/2015 - 18:55

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The majority of cholecystitis events in the ICU are acalculous. The severity of this condition among the critically ill demands this condition be treated in sufficient detail by the exam candidate.

One specific instance is Question 17 from the second paper of 2008, "Outline  the clinical manifestations, appropriate investigations, and treatment of acalculous  cholecystitis." Question 8 from the second paper of 2002 was identical.

Probably the single best reference for this topic is this 2010 review article by Huffman and Schenker.

Unless otherwise specified, the information in this quick summary is derived from their work.

In summary:

Clinical manifestations:

  • RUQ pain
  • High bilirubin
  • Cholestatic pattern of LFT elevation
  • Fever
  • Bacteraemia
  • Sympathetic right sided pleural effusion
  • Haemodynamic instability

Pathogens:

  • E.coli
  • Klebsiella
  • Proteus
  • Enterococcus
  • Bacteroides

Investigations:

  • Abdominal ultrasound
  • Abdominal CT
  • Blood cultures

Management:

  • Broad spectrum antibiotics
  • Percutaneous drainage
  • Surgical cholecystectomy (but this tends to be the last resort)

Why is this specific to the ICU?

Unlike most of the cholecystitis outside the ICU, these gall bladders are inflamed without stones. The inflammation is frequently more severe, and the progression to gangrene and septic shock is more likely.

The most likely comorbidities in the ICU are trauma, burns and sepsis.

Risk Factors for Acalculous Cholecystitis

Strongly associated factors

  • Trauma with massive transfusion
  • Any recent surgery
  • Burns
  • Sepsis
  • TPN
  • Prolonged fasting
  • Critical illness in general

Weakly associated factors

  • ERCP
  • Long hospital stay
  • Immunosuppression
  • Vasculitis
  • CBD obstruction
  • Obesity, diabetes, hypertension

Mechanism of pathogenesis

mechanism of acalculous cholecystitis

This environment, with a defenceless ischaemic gall bladder wall, gives rise to bacterial translocation into said wall. The typical features of this, on ultrasonography, include a distended gallbladder with a thickened wall and neither gallstones nor sludge inside. The wall may be emphysematous (suggesting that it is gangrenous and gas-forming anaerobes are migrating across it) and there may be gas bubbles in the gall bladder itself (the so-called “champaigne sign”). Pericholecystic fluid may be present, suggesting that inflammation is occurring; alternatively the CT abdomen may reveal a perforated gall bladder, and a collection forming in its ruins.

Unfortunately, there are no specific clinical findings that establish the diagnosis.
It therefore rests on imaging.

Radiological and Ultrasonographic Features of
Acalculous Cholecystitis
  • Thickened gall bladder wall (over 3.5-4mm)
  • Pericholecystic fluid
  • Intramural gas
  • Echogenic or hyperdense bile sludge
  • Sloughed mucosa
  • Gall bladder distension

A HIDA cholescintigraphy study is another specialised option. HIDA stands for 99Tcm-labelled hepatic iminodiacetic acid. It (or one of its various analogues) is administered IV, and its excretion into the gall bladder is measured. If the presence of the isotope is not detected in the gall bladder after 4 hours, some sort of biliary obstruction must be present. If the isotope fills the gall bladder, a fatty meal or cholecystokinin can then be administered to force the gall bladder to contract; a gall bladder ejection fraction (GBEF) of over 40% represents normal function. Generally speaking, this modality is used when the ultrasonographic and CT findings are equivocal. It can predict outcome and direct therapy: of the patients with a normal GBEF, the majority (up to 90%) end up symptom free after three months with only conservative management. One rarely needs to resort to this; authors of one study of acalculous cholecystitis remark that "hepatobiliary scintigraphy, which is used when the diagnosis is difficult, was not deemed necessary in any of the patients in this series".

Management

The management of this condition does not vary massively from the normal management of acute cholecystitis.
One may wish to cover for E.coli and Klebsiella as well as Proteus, Enterococcus and Bacteroides. Typically the surgical “triple therapy” covers for all these organisms, but keeping in mind that this condition occurs in ICU patients frequently already on antibiotics one may wish to broaden the cover or add an antifungal agent.

Options for Management of Acalculous Cholecystitis

Option

Advantages

Disadvantages

Conservative (antibiotics)
  • Few complications
  • May be the only option for high risk patients.
  • In a mixed (calculous and acalculous) group, 87% of conservatively managed patients recovered completely.
  • Patients with reasonably normal gall bladder function (over 40% GBEF) only need conservative management.
  • There is still an option to progress to one of the other treatment options.
  • May delay definitive treatment
  • The gallbladder may become necrotic and rupture, causing peritonitis
  • Patients with a severely infected gall bladder will continue to get worse, as source control has not been achieved.
Percutaneous cholecystostomy
Laparoscopic cholecystectomy
  • Fewer complications than open cholecystectomy
  • A definitive management option
  • Not an option in some patients, particularly morbidly obese patients and those with severe respiratory failure
  • Requires a surgeon familiar with the approach
  • May end up converting to open anyway, losing all benefits of the laparoscopic approach.
Open cholecystectomy
  • A definitive management option.
  • Allows for a thorough washout.
  • Accomodates weird anatomy and allows earlier maagement of surgical complications.
  • May be the only option for those with a gangrenous or perforated gall bladder.
  • Significant morbidity post operatively in the critically ill population (mortality may be up to 19%)
  •  
  •  

Ideally, to fix this problem surgically is the solution, but practically speaking this is going to be difficult in the critically ill patient.  Percutanous cholecystostomy may be the only answer; of those who respond the majority experience and improvement withn 48 hours- but in 41% it seems to make no difference to the severity of their shock, suggesting that in these patients the thick distended gallbladder was mistaken as the source of sepsis. Additionally, putting a tube though somebody’s abdominal wall is non a consequence-free step, and there are reports of horrible complications like bleeding from the liver. The drain may also dislodge during pressure area care, resulting in a spray of infected bile all over the peritoneum.

 

References

Laurila, Jouko, et al. "Acute acalculous cholecystitis in critically ill patients."Acta anaesthesiologica scandinavica 48.8 (2004): 986-991.

Wang, Ay-Jiun, et al. "Clinical predictors of severe gallbladder complications in acute acalculous cholecystitis." Heart 1500 (2003): 8.

Boland, Giles W., et al. "Percutaneous cholecystostomy in critically ill patients: early response and final outcome in 82 patients." American Journal of Roentgenology 163.2 (1994): 339-342.

Kalliafas, Stavros, et al. "Acute acalculous cholecystitis: incidence, risk factors, diagnosis, and outcome.The American surgeon 64.5 (1998): 471-475.

Huffman, Jason L., and Steven Schenker. "Acute acalculous cholecystitis: a review." Clinical Gastroenterology and Hepatology 8.1 (2010): 15-22.

Middleton, G. W., and J. H. Williams. "Diagnostic accuracy of 99Tcm-HIDA with cholecystokinin and gallbladder ejection fraction in acalculous gallbladder disease." Nuclear medicine communications 22.6 (2001): 657-661.

Savoca, PAUL E., et al. "The increasing prevalence of acalculous cholecystitis in outpatients. Results of a 7-year study." Annals of surgery 211.4 (1990): 433.

Gokhale, Shefali M., S. D. Lokare, and Pankaj Nemade. "Role of cholescintigraphy in management of acute acalculous cholecystitis." Indian journal of nuclear medicine: IJNM: the official journal of the Society of Nuclear Medicine, India 27.4 (2012): 231.

Kirkegård, J., et al. "Percutaneous Cholecystostomy is an Effective Definitive Treatment Option for Acute Acalculous Cholecystitis.Scandinavian Journal of Surgery (2015): 1457496914564107.

Zehetner, Joerg, et al. "Percutaneous Cholecystostomy Versus Laparoscopic Cholecystectomy in Patients With Acute Cholecystitis and Failed Conservative Management: A Matched-Pair Analysis." Surgical Laparoscopy Endoscopy & Percutaneous Techniques 24.6 (2014): 523-527.

Ganpathi, Iyer Shridhar, et al. "Acute acalculous cholecystitis: challenging the myths." Hpb 9.2 (2007): 131-134.

Simorov, Anton, et al. "Emergent cholecystostomy is superior to open cholecystectomy in extremely ill patients with acalculous cholecystitis: a large multicenter outcome study." The American Journal of Surgery 206.6 (2013): 935-941.