Management of Acalculous Cholecystitis
Immediate laparoscopic cholecystectomy is the first-choice treatment for acalculous cholecystitis, even in critically ill high-risk patients, and should be performed as soon as possible rather than defaulting to percutaneous drainage. 1, 2, 3
Primary Treatment: Immediate Laparoscopic Cholecystectomy
For all surgical candidates, including high-risk critically ill patients, proceed directly to laparoscopic cholecystectomy rather than percutaneous drainage. 1, 2, 3 The landmark CHOCOLATE trial definitively demonstrated that immediate cholecystectomy in high-risk patients (APACHE score 7-14) resulted in major complications in only 5% of patients compared to 53% in the percutaneous drainage group, with equivalent mortality between groups. 1, 2, 3 The complications in the drainage group were predominantly recurrent biliary events, and healthcare resource utilization was significantly lower with immediate surgery. 1, 2
Timing is critical: perform cholecystectomy as soon as possible, ideally within 7 days of hospital admission and within 10 days of symptom onset. 2, 3 Earlier surgery correlates with shorter hospital stays and fewer complications. 1
Risk Stratification and Surgical Approach
Do not let "high-risk" status deter you from surgery. 1, 2 The evidence shows that even critically ill patients with significant comorbidities benefit more from immediate cholecystectomy than from drainage. 1, 2, 3 Risk factors predicting conversion to open surgery include age >65 years, male gender, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery. 1, 3
Conversion to open cholecystectomy is not a failure—it is a valid safety option. 1, 2 Convert without hesitation when encountering severe local inflammation with dense adhesions, uncontrolled bleeding from Calot's triangle, or suspected bile duct injury. 1, 2
Consider subtotal cholecystectomy for advanced inflammation, gangrenous gallbladder, or "difficult gallbladder" where anatomy cannot be clearly identified. 1 This prevents bile duct injuries in challenging cases.
Gallbladder Drainage: Reserved for Non-Surgical Candidates Only
Percutaneous transhepatic gallbladder drainage (PTGBD) should be reserved exclusively for patients who are truly not suitable for surgery. 1, 2, 3 This includes patients with absolute anesthetic contraindications, prohibitive operative risk, or those who remain poor surgical candidates despite resuscitation. 1, 2, 3
PTGBD converts a septic patient into a non-septic patient by decompressing infected bile or pus. 1 The procedure has an 85.6% success rate with procedure-related mortality of only 0.36%, though 30-day mortality remains high at 15.4% due to underlying critical illness. 1, 3
Predictors of failure of non-operative management at 24 hours include: age >70 years, diabetes, tachycardia, and distended gallbladder at admission. 1 At 48 hours, add WBC >15,000 cells/mm³ and fever to this list. 1 If conservative management fails after 24-48 hours and strict contraindications to surgery exist, proceed to gallbladder drainage. 1
Endoscopic alternatives (ETGBD or EUS-GBD) are safe and effective alternatives to PTGBD in high-volume centers with skilled endoscopists. 1
Delayed Cholecystectomy After Drainage
For patients who undergo PTGBD, delayed laparoscopic cholecystectomy should be offered after reduction of perioperative risks. 1 Without subsequent cholecystectomy, the 1-year readmission rate is 49% with 1% in-hospital mortality. 1 However, 40% of patients who undergo PTGBD eventually proceed to delayed cholecystectomy. 1
Antibiotic Management
Administer broad-spectrum antibiotics immediately upon recognition, as this significantly impacts mortality in septic shock from biliary sources. 3 Piperacillin/tazobactam provides excellent bile penetration and appropriate coverage. 1, 3
Antibiotic duration should be 4 days for immunocompetent patients with adequate source control. 3 No postoperative antimicrobial therapy is necessary if source control is complete in uncomplicated cases. 1, 3
In complicated cases or high-risk patients for antimicrobial resistance, adapt the antibiotic regimen based on microbiological analysis from bile cultures. 1 Bile culture positivity ranges from 29-54% in acalculous cholecystitis. 1
Critical Pitfalls to Avoid
Do not delay surgery based solely on elevated APACHE scores or ASA classification. 1, 2, 3 The CHOCOLATE trial specifically included high-risk patients and demonstrated superior outcomes with immediate surgery. 1, 2, 3
Do not use PTGBD as a routine "bridge to surgery" in patients who can tolerate immediate cholecystectomy. 1, 2 This approach leads to longer hospital stays, higher readmission rates, and more complications. 1, 2
Maintain high suspicion for gallbladder perforation, which occurs in 2-11% of cases with mortality up to 12-16%. 2, 3 Immediate surgical intervention substantially decreases morbidity and mortality. 1, 2, 3
In sedated or mechanically ventilated patients, localizing right upper quadrant pain and tenderness are frequently absent. 3 Elevation in alkaline phosphatase or gamma-glutamyl transferase may help differentiate acalculous cholecystitis from other causes of sepsis. 3