What is the treatment for acalculous cholecystitis?

Treatment of Acalculous Cholecystitis

Early laparoscopic cholecystectomy is the first-choice treatment for acalculous cholecystitis in suitable patients, while percutaneous cholecystostomy is recommended for high-risk patients who are not surgical candidates. 1

Treatment Algorithm

First-line Treatment

• Surgical Management:
  • Immediate laparoscopic cholecystectomy (within 24-72 hours) is superior to percutaneous drainage in patients who can tolerate surgery 2, 1
  • Benefits include shorter hospital stays, lower complication rates, and reduced healthcare resource utilization 1

Alternative Management for High-Risk Patients

• Percutaneous Cholecystostomy:
  • Indicated for patients who are:
    • Critically ill
    • Elderly
    • In septic shock
    • Have significant comorbidities
    • Otherwise poor surgical candidates 1
  • Transhepatic approach preferred to minimize bile leakage 1
  • Effectively reduces inflammatory markers within 24-48 hours in 92% of patients 1

Specific Considerations for Acalculous Cholecystitis

Acalculous cholecystitis differs from calculous cholecystitis in several important ways:

• Often occurs in critically ill patients with underlying conditions such as:

  • Atherosclerotic heart disease
  • Recent trauma or burns
  • Post-surgery
  • Hemodynamic instability 3

• Patients with acalculous cholecystitis who undergo percutaneous cholecystostomy have:

  • Lower rates of recurrent cholecystitis (8.3%) compared to calculous cholecystitis patients (16.1%) 4
  • Lower likelihood of requiring interval cholecystectomy 4

Antibiotic Management

• First-line options for mild-to-moderate cases:

  • Cefazolin, cefuroxime, or ceftriaxone 1

• For severe or healthcare-associated cases:

  • Broader coverage with piperacillin-tazobactam, carbapenems, or cefepime plus metronidazole 1
  • Add vancomycin for potential MRSA coverage 1

• Duration:

  • Antibiotics should be discontinued after source control is achieved through cholecystectomy 1
  • For patients managed with percutaneous drainage, continue antibiotics until clinical improvement

Follow-up After Percutaneous Cholecystostomy

• Monitor for clinical improvement:

  • Decreasing fever
  • Resolving abdominal pain
  • Normalizing white blood cell count 1

• For acalculous cholecystitis specifically:

  • After recovery, further treatment such as cholecystectomy might not be needed 5
  • Recurrence rates are low (7%) in patients managed non-operatively with tube removal 5
  • Consider interval cholecystectomy only if symptoms recur

Important Caveats

• Diagnostic challenges:

  • Acalculous cholecystitis may present insidiously with unexplained fever, leukocytosis, or abnormal liver enzymes 3
  • Patients may lack typical right upper quadrant tenderness 3
  • Ultrasound, CT, and cholescintigraphy are key diagnostic tools 3

• Mortality considerations:

  • Untreated acalculous cholecystitis carries high mortality 3
  • 30-day mortality is higher in acalculous cholecystitis patients (45.2%) compared to calculous cholecystitis patients (21.2%) 4
  • Early intervention is critical to improve outcomes

• Special cases:

  • Viral hepatitis A can rarely cause acalculous cholecystitis, which may respond to conservative management 6
  • Acalculous cholecystitis can complicate other procedures like abdominal aortic aneurysm repair 7