From the Guidelines
Acalculous cholecystitis should be treated with urgent gallbladder drainage, either through percutaneous cholecystostomy for unstable patients or laparoscopic cholecystectomy for those who can tolerate surgery, along with broad-spectrum antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours. The treatment of acalculous cholecystitis involves a combination of medical and surgical interventions. According to the most recent study 1, antibiotic therapy should be administered for 4-7 days based on clinical conditions and inflammation indices.
Key Considerations
- The pathophysiology of acalculous cholecystitis involves gallbladder stasis and ischemia leading to inflammation and potential necrosis 1.
- Risk factors for acalculous cholecystitis include prolonged fasting, TPN use, major surgery, trauma, burns, or sepsis 1.
- Without prompt intervention, complications include gangrene, perforation, and sepsis, with mortality rates of 30-50% in critically ill patients 1.
Treatment Options
- Percutaneous cholecystostomy can be both diagnostic and therapeutic, and it is usually considered safe in hospitalized patients suspected of having acalculous cholecystitis 1.
- Laparoscopic cholecystectomy is a viable option for patients who can tolerate surgery, and it is often preferred over percutaneous cholecystostomy due to its lower risk of major complications 1.
- Cholecystostomy may be an option for acute cholecystitis in patients with multiple comorbidities and unfit for surgery patients who do not show clinical improvement after antibiotic therapy for days 1.
Antibiotic Therapy
- Broad-spectrum antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours should be administered promptly 1.
- The duration of antibiotic therapy should be 4-7 days based on clinical conditions and inflammation indices 1.
Post-Treatment Care
- Patients who receive percutaneous cholecystostomy should have eventual cholecystectomy once the patient stabilizes, typically after 4-6 weeks 1.
- Patients should receive close monitoring and follow-up care to prevent complications and ensure optimal outcomes 1.
From the Research
Definition and Presentation
- Acalculous cholecystitis is defined as acute inflammation of the gallbladder in the absence of gallstones 2.
- Patients are usually critically ill with atherosclerotic heart disease, recent trauma, burn injury, surgery, or hemodynamic instability 2.
- The presentation of acute acalculous cholecystitis may be insidious, characterized by unexplained fever, leukocytosis, hyperamylasemia, or abnormal aminotransferases, and patients often lack right upper quadrant tenderness 2.
Diagnostic Evaluation
- Diagnostic evaluation includes ultrasonography, computerized tomography, and cholescintigraphy 2.
- Imaging findings can be either insensitive or non-specific, making diagnosis challenging 3.
Treatment Options
- Definitive treatment consists of cholecystectomy or, in poor surgical candidates, cholecystostomy 2.
- Endoscopic therapy with nasobiliary drainage and lavage is an effective treatment option in patients unable to tolerate surgery or cholecystostomy 2.
- Percutaneous cholecystostomy, surgical cholecystectomy, or endoscopically placed metal stent through the gastrointestinal tract into the gallbladder are also management options 3.
- Endoscopic ultrasound-guided gallbladder drainage is a novel drainage approach for patients who are poor candidates for surgery 3.
- Nonsurgical management, such as antibiotics alone or percutaneous cholecystostomy, might be effective in selected patients 4.
Risk Factors and Outcomes
- The risk of acalculous cholecystitis increases in patients with advanced age and cerebrovascular accidents 4.
- Incidence of gangrenous cholecystitis is higher in acalculous cholecystitis compared to acute calculous cholecystitis 4.
- The overall therapeutic outcomes for patients do not differ statistically between acalculous and acute calculous cholecystitis groups, irrespective of treatment modalities 4.
- The recurrence rate after nonsurgical treatment is significantly lower in the acalculous cholecystitis group than in the acute calculous cholecystitis group 4.
- In moderate acute cholecystitis after percutaneous cholecystostomy, patients receiving narrow-spectrum antibiotics have comparable clinical outcomes as those treated with broad-spectrum antibiotics 5.