What is the treatment for acalculous cholecystitis?

Treatment of Acalculous Cholecystitis

For acalculous cholecystitis, early percutaneous cholecystostomy is the recommended first-line treatment for critically ill patients or those with significant comorbidities who are poor surgical candidates, while laparoscopic cholecystectomy remains the definitive treatment for patients who can tolerate surgery. 1

Initial Management

• Antibiotic Therapy: Start immediately upon diagnosis

  • First-line options for community-acquired infections:
    • Beta-lactam/beta-lactamase inhibitors: Amoxicillin/Clavulanate or Piperacillin/Tazobactam
    • Cephalosporin-based regimens: Ceftriaxone + Metronidazole
    • For beta-lactam allergy: Ciprofloxacin/Levofloxacin + Metronidazole or Moxifloxacin
  • Duration: 3-5 days for uncomplicated cases 1
  • Initially IV, then switch to oral when clinical improvement occurs

• Fluid Resuscitation: Goal-directed fluid therapy 1

• Pain Management:

  • First-line: NSAIDs
  • Alternative/adjunct: Acetaminophen 1

Definitive Treatment Options

1. Percutaneous Cholecystostomy

• Primary indication: High-risk patients unfit for immediate surgery due to:

  • Severe sepsis
  • Multiple comorbidities
  • Hemodynamic instability 1, 2

• Effectiveness:

  • Technical success rate: 100%
  • Symptom resolution: 93% within 4 days
  • Low complication rate 2

• Long-term outcomes:

  • Can be definitive management in selected patients
  • Recurrence rate after tube removal: only 7% 2
  • May not require subsequent cholecystectomy in many cases

2. Laparoscopic Cholecystectomy

• Primary indication: Hemodynamically stable patients who can tolerate surgery
• Timing: Early cholecystectomy (within 7 days of admission) is preferred 1
• Benefits: Definitive treatment that prevents recurrence

3. Endoscopic Management

• Indication: Patients unable to tolerate surgery or percutaneous drainage
• Approach: Nasobiliary drainage and lavage 3

Special Considerations

Underlying Causes

• Acalculous cholecystitis often occurs in:
  • Critically ill patients
  • Patients with atherosclerotic heart disease
  • Recent trauma, burns, or surgery
  • Viral infections (e.g., hepatitis A) 4, 3

Diagnostic Approach

• First-line imaging: Abdominal ultrasonography
  • Look for: gallbladder wall thickening, pericholecystic fluid, distended gallbladder, positive sonographic Murphy's sign 1
• Additional imaging:
  • Triphasic CT with IV contrast: For detecting fluid collections, bilomas
  • CE-MRCP: For bile duct visualization 1
  • Cholescintigraphy: Helpful in difficult cases 3

Prognosis and Complications

• Mortality: Higher in acalculous (45.2%) vs. calculous cholecystitis (21.2%) 1
• Complications if untreated:
  • Gangrene
  • Perforation (mortality 12-16%)
  • Empyema 1, 3

Treatment Algorithm

1. Assess surgical risk:

   • If low risk → Laparoscopic cholecystectomy
   • If high risk → Percutaneous cholecystostomy

2. After percutaneous cholecystostomy:

   • If clinical improvement → Consider tube removal without further intervention
   • If persistent symptoms or recurrence → Consider interval cholecystectomy when condition improves

3. Follow-up:

   • No regular follow-up required for asymptomatic patients
   • Educate patients about symptoms requiring medical attention (persistent RUQ pain, fever, jaundice) 1

Pitfalls and Caveats

• Diagnosis may be challenging as patients often lack classic RUQ tenderness
• Symptoms may be insidious (unexplained fever, leukocytosis, abnormal liver enzymes)
• Failure to recognize ongoing infection beyond 7 days requires diagnostic investigation rather than simply extending antibiotics 1, 3
• Microbiological cultures should be obtained whenever possible to guide targeted therapy 1