What is the treatment for acalculous cholecystitis?

Treatment for Acalculous Cholecystitis

Early laparoscopic cholecystectomy is the first-choice treatment for acalculous cholecystitis, as it results in significantly fewer complications and better healthcare resource utilization compared to other interventions. 1

Primary Treatment Algorithm

• Early laparoscopic cholecystectomy should be performed within 7-10 days of symptom onset in patients who are suitable surgical candidates 1, 2
• Laparoscopic cholecystectomy is superior to percutaneous transhepatic gallbladder drainage (PTGBD) even in high-risk patients, with significantly lower complication rates (5% vs 53%) 3
• Early surgical intervention leads to significantly less utilization of healthcare resources and fewer readmissions for gallstone-related diseases 3, 1

Management for Non-Surgical Candidates

• Percutaneous transhepatic gallbladder drainage (PTGBD) is recommended for patients who are not suitable for surgery, particularly those with sepsis due to gallbladder empyema 3, 1
• PTGBD has a high success rate (85.6%) with a low procedure-related mortality rate (0.36%), though 30-day mortality remains high at 15.4% due to underlying conditions 3
• Gallbladder drainage converts a septic patient with acalculous cholecystitis into a non-septic patient by decompressing the infected bile or pus 3
• Endoscopic alternatives including transpapillary gallbladder drainage should be performed in high-volume centers by skilled endoscopists 1

Predictors of Treatment Failure

• Predictors of failure for non-operative management at 24 hours include age >70 years, diabetes, tachycardia, and distended gallbladder 3, 1
• At 48-hour follow-up, WBC count >15,000 cells/mm³, fever, and age >70 years predict failure of non-operative management 3
• Approximately 30% of patients with mild acute cholecystitis who do not undergo cholecystectomy will develop recurrent gallstone-related complications during long-term follow-up 3

Delayed Cholecystectomy Considerations

• Delayed laparoscopic cholecystectomy should be considered after reduction of perioperative risks to decrease readmission for relapse or gallstone-related disease 3
• Studies show that 40% of patients underwent delayed laparoscopic cholecystectomy after PTGBD, while those who did not had a 49% one-year readmission rate 3
• For patients initially treated with percutaneous drainage, subsequent cholecystectomy should be considered once their condition stabilizes to prevent recurrent biliary events 4, 5

Special Considerations and Pitfalls

• Delaying surgery in suitable candidates based solely on age or comorbidities is not recommended, as evidence shows early laparoscopic cholecystectomy is safe and effective even in high-risk patients 1
• In critically ill patients with multiple comorbidities where laparoscopic approach is risky, percutaneous cholecystostomy may be the safest intervention 5
• Overuse of gallbladder drainage procedures in patients who could safely undergo surgery should be avoided, as this leads to higher mortality rates, longer hospital stays, and increased readmissions 1
• Acalculous cholecystitis most commonly occurs in critically ill patients, especially those with trauma, surgery, shock, burns, sepsis, or those on total parenteral nutrition 6

Diagnostic Approach

• Diagnosis is challenging as findings of right upper-quadrant pain, fever, leukocytosis, and abnormal liver tests are not specific 6
• Sequential sonograms and hepatic iminodiacetic acid scans are the most reliable modalities for diagnosis 6
• Early diagnosis is crucial as acalculous cholecystitis is associated with high mortality if not treated promptly 6, 5