What is the management of acalculous cholecystitis?

Management of Acalculous Cholecystitis

Early intervention with either cholecystectomy or gallbladder drainage is the recommended approach for acalculous cholecystitis, with cholecystectomy being the definitive treatment of choice when patients are suitable surgical candidates. 1, 2

Diagnosis

• Clinical presentation: Right upper quadrant pain, fever, leukocytosis, and abnormal liver tests (though these findings are nonspecific) 2
• Imaging studies:
  • Ultrasonography is first-line (findings: gallbladder wall thickening, pericholecystic fluid, distended gallbladder, positive sonographic Murphy's sign) 3
  • Hepatic iminodiacetic acid (HIDA) scans are recommended when ultrasound findings are equivocal 2

Treatment Algorithm

1. Surgical Management

• For suitable surgical candidates:
  • Early laparoscopic cholecystectomy is the definitive treatment 1, 4
  • Should be performed within 24-72 hours of presentation for optimal outcomes 3
  • Associated with shorter hospital stays, fewer complications, and lower mortality rates 3

2. Non-surgical Management (for patients not suitable for surgery)

• Gallbladder drainage:
  • Recommended for patients who are not suitable for surgery to convert a septic patient into a non-septic one 1
  • Options include:
    • Percutaneous transhepatic gallbladder drainage (PTGBD) - traditional approach
    • Endoscopic transpapillary gallbladder drainage (ETGBD)
    • Ultrasound-guided transmural gallbladder drainage (EUS-GBD)
  • ETGBD and EUS-GBD should be considered safe and effective alternatives to PTGBD if performed in high-volume centers by skilled endoscopists 1
  • Percutaneous cholecystostomy may be a definitive therapy with no need for subsequent elective cholecystectomy in acalculous cholecystitis 4

3. Antibiotic Therapy

• For uncomplicated cases:

  • Antibiotics can be discontinued after the focus of infection is controlled by cholecystectomy 1
  • First-line options include:
    • Ticarcillin/Clavulanate
    • Ceftriaxone + Metronidazole
    • Piperacillin/Tazobactam (loading dose of 6g/0.75g followed by 4g/0.5g every 6 hours) 3

• For complicated cases:

  • Broad-spectrum antibiotics recommended 1
  • Options include:
    • Piperacillin/Tazobactam
    • Cefepime + Metronidazole
    • Ertapenem (especially for patients with risk factors for ESBLs) 3
  • For penicillin allergy: Ciprofloxacin + Metronidazole, Levofloxacin + Metronidazole, or Moxifloxacin 3
  • Duration: 3-5 days for non-critical, immunocompetent patients 3

• Microbiological cultures:

  • Always obtain intraoperative bile cultures to guide targeted antibiotic therapy 3, 5
  • Adapt antibiotic regimen based on culture results, especially in patients at high risk for antimicrobial resistance 1

Special Considerations

• Elderly patients:

  • Early laparoscopic cholecystectomy is still recommended when feasible 1
  • Broader spectrum antibiotics may be needed, especially for patients from institutions due to risk of multidrug-resistant organisms 1, 3
  • Consider pharmacokinetic changes and potential drug interactions 1

• High-risk patients:

  • The CHOCOLATE Study showed that surgery is preferred over biliary drainage in high-risk patients with acute cholecystitis 1
  • For those truly unfit for surgery, gallbladder drainage is recommended 1

• Follow-up after drainage:

  • Consider delayed laparoscopic cholecystectomy after reduction of perioperative risks to decrease readmission for relapse 1
  • Monitor for clinical improvement (decreasing fever, abdominal pain, normalizing white blood cell count) 3
  • Watch for complications such as gangrenous, hemorrhagic, or emphysematous cholecystitis, and gallbladder perforation 3

Pitfalls and Caveats

• Acalculous cholecystitis is often difficult to diagnose due to nonspecific clinical findings and complex clinical settings 2
• Higher index of suspicion needed in elderly male patients with vascular disease, as they represent a significant proportion of outpatient cases 6
• Avoid unnecessary prolonged antibiotic therapy when the source of infection has been controlled 1, 3
• Recognize that some cases of acalculous cholecystitis may be associated with viral infections (e.g., EBV) rather than bacterial causes, where antibiotics can be discontinued once the etiology is confirmed 7