What is the treatment for acute acalculus cholecystitis?

Treatment for Acute Acalculous Cholecystitis

The treatment for acute acalculous cholecystitis should be urgent laparoscopic cholecystectomy within 7-10 days of symptom onset, combined with appropriate intravenous antibiotics, as recommended by the World Society of Emergency Surgery guidelines. 1

Diagnosis and Initial Assessment

• Ultrasonography is the first-line imaging technique for suspected acalculous cholecystitis, with key findings including:

  • Gallbladder wall thickening
  • Pericholecystic fluid
  • Distended gallbladder
  • Positive sonographic Murphy's sign
  • Absence of gallstones (defining feature of acalculous cholecystitis)

• When ultrasound is inconclusive, hepatobiliary scintigraphy (HIDA scan) is the gold standard with higher sensitivity and specificity 1

Treatment Algorithm

1. Surgical Management

• First-line treatment: Urgent laparoscopic cholecystectomy within 7-10 days of symptom onset 1
• Surgical options based on patient condition:
  • Laparoscopic cholecystectomy: Preferred for most patients
  • Subtotal cholecystectomy: Valid option in cases of advanced inflammation or difficult anatomy
  • Open cholecystectomy: Consider in cases of severe local inflammation, adhesions, bleeding in the Calot triangle, or suspected bile duct injury

2. Alternative Management for High-Risk Patients

• Percutaneous cholecystostomy is reserved for:

  • Critically ill patients with multiple comorbidities unfit for surgery
  • Patients who don't improve after 3-5 days of antibiotic therapy 1, 2
  • Patients with severe sepsis or significant underlying comorbidities 3

• Endoscopic therapy with nasobiliary drainage and lavage may be considered in patients unable to tolerate surgery or cholecystostomy 4

3. Antibiotic Management

• First-line antibiotic options include:

  • Amoxicillin/Clavulanate 2g/0.2g q8h
  • Ceftriaxone + Metronidazole
  • Ciprofloxacin + Metronidazole
  • Levofloxacin + Metronidazole
  • Moxifloxacin
  • Ertapenem
  • Tigecycline 1

• For healthcare-associated infections and complicated cases: Piperacillin/Tazobactam 1

• Add coverage against Enterococci with glycopeptide antibiotics (e.g., vancomycin) or oxazolidine antibiotics (e.g., linezolid) when indicated 1

• Duration: Typically 4 days if source control is adequate; may extend up to 7 days based on clinical condition and inflammatory markers 1

• Always obtain bile samples for culture to guide targeted antibiotic therapy 5

Special Considerations

• Acalculous cholecystitis has a higher mortality rate (45.2%) compared to calculous cholecystitis (21.2%) 1

• Acalculous cholecystitis often occurs in critically ill patients with:

  • Atherosclerotic heart disease
  • Recent trauma
  • Burn injury
  • Surgery
  • Hemodynamic instability 4

• Clinical presentation may be insidious with:

  • Unexplained fever
  • Leukocytosis
  • Hyperamylasemia
  • Abnormal liver function tests
  • Patients may lack right upper quadrant tenderness 4

• In rare cases, acalculous cholecystitis can be caused by viral infections such as hepatitis A, which may respond to conservative management 6

Long-term Management

• For patients who undergo percutaneous cholecystostomy without subsequent cholecystectomy, the risk of recurrent cholecystitis is approximately 7% 3
• Some studies suggest that after recovery with percutaneous cholecystostomy, further treatment such as cholecystectomy might not be needed in selected cases 3

Pain Management

• First-line therapy: Oral nonsteroidal anti-inflammatory drugs (NSAIDs)
• Alternative or adjunct: Acetaminophen 1

Monitoring and Follow-up

• Daily assessment of clinical response
• Monitor renal function, especially in elderly patients with CKD
• Goal-directed fluid therapy for resuscitation 1
• For patients with ongoing signs of infection beyond 7 days, further diagnostic investigation is warranted 1