Management of Acute Acalculous Cholecystitis
Immediate Surgical Intervention is Mandatory
Immediate cholecystectomy (laparoscopic or open, depending on patient stability) is the definitive treatment for acute acalculous cholecystitis, as this condition carries extremely high mortality if untreated and requires urgent source control. 1
Initial Stabilization and Diagnosis
- Begin immediate resuscitation with IV fluids, broad-spectrum antibiotics (piperacillin-tazobactam 4g/0.5g IV every 6 hours for critically ill patients), and hemodynamic support 2, 3
- Obtain urgent imaging with ultrasound as first-line (showing gallbladder wall thickening >3mm, pericholecystic fluid, distended gallbladder without stones) or CT with IV contrast if diagnosis unclear 2, 1
- Recognize that acalculous cholecystitis presents insidiously in critically ill patients—look for unexplained fever, leukocytosis, hyperamylasemia, or elevated aminotransferases even without right upper quadrant tenderness 1
Definitive Surgical Management
- Perform emergency cholecystectomy (open or laparoscopic based on patient stability and surgical expertise) as soon as the patient is hemodynamically stabilized 4, 1
- Laparoscopic approach is preferred when feasible, but open cholecystectomy should be performed without hesitation in unstable patients or when perforation is suspected 4
- Intraoperative findings often include gallbladder necrosis, gangrene, or perforation—perform thorough peritoneal lavage and drainage 4
Critical Management Principles for High-Risk Patients
- Percutaneous cholecystostomy is NOT definitive therapy for acalculous cholecystitis and should only serve as a temporizing bridge to surgery in patients too unstable for immediate operation 5, 1
- Even in critically ill patients, early surgical intervention is superior to drainage procedures alone—the CHOCOLATE trial demonstrated that laparoscopic cholecystectomy results in fewer major complications than percutaneous drainage 5, 4
- If percutaneous cholecystostomy is placed as a bridge procedure, plan for interval cholecystectomy once the patient stabilizes (typically within 4-6 weeks) 5, 6
Special Considerations for Critically Ill Populations
- Acalculous cholecystitis occurs predominantly in ICU patients with recent trauma, burns, major surgery, sepsis, or prolonged mechanical ventilation 1
- Maintain high clinical suspicion in patients with atherosclerotic heart disease, hemodynamic instability, or multiple organ dysfunction 1
- Mortality approaches 30-50% if diagnosis is delayed or treatment is inadequate, making early recognition and intervention paramount 5, 1
Antibiotic Therapy Duration
- Continue broad-spectrum antibiotics covering gram-negative aerobes and anaerobes until definitive source control is achieved 2, 3
- For uncomplicated cases with adequate surgical source control, discontinue antibiotics within 24 hours postoperatively 2, 4
- For complicated cases (perforation, abscess, gangrene), continue antibiotics for 3-5 days postoperatively based on clinical response 4
Common Pitfalls to Avoid
- Never rely on percutaneous drainage alone as definitive therapy—this significantly increases mortality in acalculous cholecystitis 4, 1
- Do not delay surgery waiting for "optimal" conditions in critically ill patients—the gallbladder will continue to necrose and perforate 1
- Do not dismiss the diagnosis based on absence of right upper quadrant tenderness—critically ill patients often have altered mental status or are sedated 1
- Avoid attributing fever and leukocytosis solely to other ICU complications without imaging the gallbladder 1