Advances in the Study of Acute Acalculous Cholecystitis: A Comprehensive Review.

BACKGROUND: Acute acalculous cholecystitis (AAC) is characterized by acute necrotizing inflammation with no calculi and is diagnosed based on imaging, intraoperative, and pathological examinations. KEY MESSAGE: Although AAC has been studied clinically for a long time, it remains difficult to diagnose and treat. The pathogenesis of AAC is still not fully understood, and it is often regarded as a relatively independent clinical disease that is different from acute calculous cholecystitis (ACC). Pathological studies suggest that AAC is the manifestation of a critical systemic disease, while ACC is a local disease of the gallbladder. SUMMARY: Concerning the pathogenesis, diagnosis, and treatment of AAC, we reviewed the research progress of AAC, which will enhance the understanding of the early diagnosis and treatment of AAC.

Acute Acalculous Cholecystitis: Think of Hepatitis A Infection and Do Not Underestimate Pain.

ABSTRACT: A 14-year-old adolescent girl presented with severe abdominal pain, tenderness, and guarding in the right upper quadrant associated with nonbilious vomiting, scleral icterus, and fever. Laboratory tests were consistent with acute hepatitis A virus-related cholestatic hepatitis. A point-of-care ultrasound showed mild gallbladder wall thickening with increased color Doppler flow and pericholecystic fluid collection, in the absence of gallstones or biliary ducts dilatation, thus suggesting acute acalculous cholecystitis. Both the clinical symptoms and the point-of-care ultrasound findings completely resolved within 1 week after admission with conservative treatment.

Chronic Acalculous Cholecystitis in Children With Biliary Symptoms: Usefulness of Hepatocholescintigraphy.

OBJECTIVES: Chronic acalculous cholecystitis (CAC) increasingly is being diagnosed as a cause of recurring biliary symptoms in children, but its clinical diagnosis remains challenging. The primary objective was to evaluate the utility of hepatocholescintigraphy in pediatric patients with suspected CAC. A secondary objective was to describe their clinical follow-up after diagnosis. METHODS: Medical records of patients (aged 9-20 years) who underwent hepatocholescintigraphy from February 2008 to January 2012 were reviewed. Patients with gallstones, and with ≤1 year of clinical follow-up, and studies without gallbladder (GB) stimulation were excluded. GB ejection fraction (GBEF) of <35% after sincalide or fatty meal (Lipomul) stimulation were considered abnormal. Diagnosis of CAC was based on histopathology after cholecystectomy. Patients with negative GB pathology, or complete resolution of symptoms without surgery, or alternative diagnoses for persistent symptoms were considered to not have CAC. RESULTS: Eighty-three patients formed the study group (median age 14.9 years), of which 81.9% were girls. Median duration of symptoms and clinical follow-up were 6 months and 2.9 years, respectively. Fifty-two patients had at least 1 study with sincalide and 36 patients had at least 1 study with Lipomul. Initial cholescintigraphy was 95.0% sensitive and 73.0% specific in diagnosing CAC, with a negative predictive value of 97.9%. Of the 31 patients with abnormal GBEF, 22 underwent cholecystectomy with improvement in pain in 72.7%, whereas all of the 9 without surgery improved. CONCLUSIONS: Hepatocholescintigraphy is useful for excluding CAC, although the clinical implications of an abnormal GBEF need to be further defined.

Acute Acalculous Cholecystitis in Hospitalized Patients With Hematologic Malignancies and Prognostic Importance of Gallbladder Ultrasound Findings.

OBJECTIVES: Patients with hematologic malignancies, especially those with acute disease or those receiving intense chemotherapy, are known to develop acute acalculous cholecystitis (AAC). The aim of this study was to evaluate the diagnostic and prognostic value of the established ultrasound (US) diagnostic criteria for AAC in patients with acute hematologic malignancies who were clinically suspected to have AAC. METHODS: We retrospectively studied the US findings of the gallbladder in patients with hematologic malignancies and correlated these findings with the duration of clinical symptoms, complications, and gallbladder-specific mortality. The major criteria were a 3.5-mm or thicker wall, pericholecystic fluid, intramural gas, and a sloughed mucosal membrane. The minor criteria were echogenic bile and hydrops (gallbladder distension > 4 cm). Ultrasound findings were considered positive if they included 2 major criteria or 1 major and 2 minor criteria. RESULTS: Ninety-four (25.5%) of 368 patients with hematologic malignancies had clinical signs of AAC during their acute phase of illness or during intense chemotherapy. Forty-three (45.7%) of these 94 patients had AAC-positive test results based on US criteria. The mean duration of symptoms was significantly longer (7.8 days) in this group than among the patients with negative test results (3.9 days; P < .001). Patients with positive test results had a higher rate of complications or mortality (20.9%) than those with negative test results (0%; P < .001). CONCLUSIONS: Symptomatic patients who meet the US criteria for the diagnosis of AAC have a poor prognosis. Other patients require a close follow-up US examination within 1 week to detect early progression.

Acalculous Cholecystitis: Is an Elective Interval Cholecystectomy Necessary.

BACKGROUND: Acute acalculous cholecystitis (AAC) accounts for 5-10% of cases of acute cholecystitis. The advantage of interval cholecystectomy for patients with AAC is unclear. Therefore, a retrospective analysis of patients diagnosed with AAC at our institution was performed over a 5-year period. METHODS: Patients were identified via hospital coding using the keywords "acalculous cholecystitis, cholecystostomy and gall bladder perforation." Follow-up data was obtained by performing a retrospective review of the patients' hospital records. RESULTS: A total of 33 patients with AAC were identified and followed for a median period of 18 months. The median age at presentation was 70 (10-96) and American Society of Anesthesiologists (ASA) grade was 3 (1-5). Twenty-three patients (70%) were treated with antibiotics alone, 7 patients (21%) with percutaneous cholecystostomy and 3 patients (9%) with laparoscopic cholecystectomy. The 90-day mortality rate was 30% with significant correlation to comorbid status, as all deaths occurred in ASA grade 3-5 individuals (p = 0.020). Two patients (6%) developed recurrent AAC and were managed non-operatively. CONCLUSION: Antibiotics and cholecystostomy were the mainstay of AAC management, and comorbid status influenced related mortality. Our results suggest that it appears safe to avoid interval cholecystectomy in patients who recover from AAC, as they are typically high-risk surgical candidates.

Acalculous cholecystitis in a female with cardiac device-related infective endocarditis.

Acute acalculous cholecystitis (AAC) is a necroinflammatory disease of the gallbladder with no gallstones present. ACC is known to be a serious, even potentially lethal complication observed mainly in patients with various severe underlying conditions including trauma, burn and sepsis. Infection of cardiac implantable electronic devices may lead to cardiac device-related infective endocarditis (CDRIE). The authors describe a case of a 55-year-old female with a history of advanced heart failure and implantation/reimplantation of biventricular pacemaker/defibrillator (CRT-D) for cardiac resynchronization therapy. She was admitted presently due to the symptoms of septicemia. Echocardiography revealed CDRIE with mobile vegetations on pacemaker leads; chest computed tomography showed pulmonary infarctions. Staphylococcus aureus was cultured from the blood. Antibiotics were applied in accordance with antimicrobial susceptibility and were continued after percutaneous leads extraction and pacemaker explantation. After 6 weeks of hospitalization, nonspecific abdominal symptoms developed, ultrasonography and computed tomography confirmed AAC diagnosis. Laparoscopic cholecystectomy was performed. To the best of the authors' knowledge, the case presented is the first report of ACC in a patient with CDRIE due to infection of pacemaker leads.

An unusual etiology of abdominal pain in children.

The first case of cholecystitis acalculous by Cryptosporidium in onco-hematology pediatric patient was described in this work.

Acute acalculous cholecystitis with eosinophilic infiltration.

We report a case of acute acalculous cholecystitis with eosinophilic infiltration. A previously healthy 6-year-old boy was referred with right abdominal pain. Imaging demonstrated marked thickening of the gallbladder wall and peri-cholecystic effusion. Acute acalculous cholecystitis was diagnosed. Symptoms persisted despite conservative treatment, therefore cholecystectomy was performed. Pathology indicated infiltration of eosinophils into all layers of the gallbladder wall. The postoperative course was uneventful and the patient has had no further symptoms. Eosinophilic cholecystitis is acute acalculous cholecystitis with infiltration of eosinophils. The causes include parasites, gallstones, allergies, and medications. In addition, it may be seen in conjunction with eosinophilic gastroenteritis, eosinophilic pancreatitis, or both. An allergic reaction to abnormal bile is thought to be the underlying cause. The present case did not fulfill the diagnostic criteria of eosinophilic cholecystitis, but this may have been in the process of developing.

Acalculous cholecystitis or biliary dyskinesia for Epstein-Barr virus gallbladder involvement?

We present two patients with Epstein-Barr virus (EBV) infection related to gallbladder involvement. Such an association is already known as EBV induced acalculous cholecystitis, diagnosed on the basis of ultrasonographic findings. In our patients, radioisotopic cholescintigraphy was also performed and it showed that gallbladder was visualized in both patients in contrast to that what can be observed in cases of cholecystitis. However, the value of ejection fraction was compatible with biliary dyskinesia. We, therefore, consider that impaired gallbladder contractility in EBV infection cases may actually represent biliary dyskinesia and not acalculous cholecystitis taking into account the radioisotopic findings and the self limited course of the disorder.

[Acute acalculous cholecystitis: from common to rare causes]. / Akut acalculosus cholecystitis: a mindennapostól a nagyon ritkáig.

Diagnostic and therapeutic approaches of acute calculous cholecystitis are well defined. Cholecystectomy is among the most frequently performed surgical interventions. In contrast, acute acalculous cholecystitis is a secondary condition; its cause may be difficult to determine and indication for surgical intervention has not been clearly established. The authors summarize the primary causes of acute acalculous cholecystitis and discuss ultrasonographic features which may help the decision to perform cholecystectomy in patients with acalculous cholecystitis.

[Assessment of the effectiveness of laser reflexotherapy in combined treatment of patients with chronic acalculous cholecystitis].

AIM: To study effects of laserpuncture in combined treatment of chronic non-calculous cholecystitis on motor function gallbladder, clinical symptoms. MATERIALS AND METHODS: 73 patients of chronic non-calculous cholecystitis were divided in to groups: 35 patients were received treated only by the means of standard therapy (the control group), 38 patients were received a course laserpuncture as part of complex treatment (the study group). RESULTS: Influence laser radiation on acupuncture points was found to induce positive therapeutic effect, such as: decrease the durations of clinical symptoms, correction of motor function gallbladder. CONCLUSION: Laserpuncture is an effective method of non-calculous cholecystitis treatment and can be included in relevant combined schemes.

Acute acalculous cholecystitis: a rare complication of snake bite.

Snake bite is an environmental and occupational hazard in many tropical and subtropical countries. It demands a high level of knowledge and skill in managing the envenomation syndrome. Herein, we describe a rare case of acute acalculous cholecystitis (AAC) that developed in a 36-year-old man after an Indian cobra (Naja naja) bite in the absence of any other predisposing factors for AAC. The probable mechanisms for the occurrence of AAC have been highlighted. Recognizing the possibility of such a complication after envenomation will definitely aid in early diagnosis and, subsequently, a better outcome.

Can percutaneous cholecystostomy be a definitive management for acute acalculous cholecystitis?

GOALS: To evaluate the safety, efficacy, and long-term outcome of percutaneous cholecystostomy without additional cholecystectomy as a definitive treatment for acute acalculous cholecystitis (AAC). BACKGROUND: AAC mainly occurs in seriously ill patients, and for those considered to be at high-risk for cholecystectomy, immediate percutaneous cholecystostomy can be a simple alternative interim treatment. However, no consensus has been reached on the issue of additional cholecystectomy. STUDY: The medical records of 57 patients that underwent percutaneous cholecystostomy for AAC at a single institution between 1995 and 2010 were retrospectively analyzed. RESULTS: Percutaneous cholecystostomy was technically successful in all patients, and no major complications relating to the procedure were encountered. Symptoms resolved within 4 days in 53 of the 57 (93%) patients. The in-hospital mortality rate was 21% (11/57) and elective cholecystectomy was performed in 18/57 (31%). Twenty-eight patients were managed non-operatively and cholecystostomy tubes were subsequently removed. These 28 patients were follow-up over a median 32 months and recurrent cholecystitis occurred in 2 (7%). CONCLUSION: Percutaneous cholecystostomy is an effective procedure and a good alternative for patients unfit to undergo immediate surgery because of severe sepsis or an underlying comorbidity. After patients with AAC have recovered from percutaneous cholecystostomy, further treatment such as cholecystectomy might not be needed.

Spontaneous perforation of acalculous gall bladder presenting as acute abdomen.

BACKGROUND: Acute abdominal pain is commonly encountered in the emergency department (ED), but a diagnosis of gall bladder perforation (GBP) is rarely considered in the absence of predisposing factors. OBJECTIVES: This article will highlight the risk factors, diagnosis, and management of GBP, a rare but potentially life-threatening biliary pathology. CASE REPORT: A 73-year-old diabetic man presented to the ED with a 12-h history of severe upper abdominal pain. He was hemodynamically stable, but abdominal examination showed distention, guarding, and diffuse tenderness. Abdominal X-ray study showed mildly distended small bowel loops without any air-fluid levels. Abdominal sonography revealed mild ascites and pericholecystic fluid collection but no gall bladder calculi. Laboratory reports documented a white blood cell count of 13,700/mm(3) and elevated serum amylase of 484 IU/L. A contrast-enhanced computed tomography (CT) scan of the abdomen suggested discontinuity of the gall bladder wall along with fluid accumulation in the pericholecystic, perihepatic, right subphrenic, and right paracolic spaces. In view of the possibility of spontaneous GBP developing as a complication of acute acalculous cholecystitis, laparotomy was planned. At surgery, several liters of bile-stained peritoneal fluid were aspirated and inspection of the gall bladder revealed a perforation at the fundus. After cholecystectomy, the patient had an uneventful recovery. CONCLUSION: The diagnosis of spontaneous gall bladder perforation should be considered in elderly patients presenting to the ED with symptoms and signs of peritonitis even in the absence of pre-existing gall bladder disease. Abdominal CT scan is an invaluable tool for the diagnosis, and early surgical intervention is usually life-saving.

Sonographic gallbladder abnormality is associated with intravenous immunoglobulin resistance in Kawasaki disease.

OBJECTIVE: Kawasaki disease (KD) is an acute systematic vasculitis in children which causes coronary arterial lesions and hydrops of gallbladder. Our objective is to correlate the clinical significance and influence on disease outcome of patients with gallbladder abnormalities in Kawasaki dissease. METHODS: Children who met KD diagnosis criteria and were admitted for IVIG treatment were retrospectively enrolled for analysis. Patients with abdominal sonography were divided into 2 groups based on the absence (Group A, N = 61) or presence (Group B, N = 16) of gallbladder abnormalities (GBA), defined as hydrops or acalculous cholecystitis. Between the two groups, clinical features, demographic data (including admission days, coronary artery lesions, IVIG resistance), and laboratory data before/after IVIG treatment were collected for analysis. RESULTS: The presence of sonographic gallbladder abnormalities is correlated with higher levels of serum CRP, GPT, and neutrophils. It also points to an increased number of IVIG resistance rates in group B. There was no significant statistical difference among clinical features, age, gender, admission days, or coronary artery lesions between the two groups. CONCLUSION: Sonographic gallbladder abnormalities are associated with higher CRP, GPT, neutrophil and IVIG resistance in KD. It can be used as a predictor of IVIG resistance in patients with KD.

Acalculous candidal cholecystitis after pediatric renal transplant.

AAC caused by Candida is an uncommon entity usually seen in the critically ill. Here, we present the case of an 18-month-old renal transplant patient who developed candidal AAC during the post-operative period. Previous articles have addressed acalculous cholecystitis secondary to a variety of causes, or addressed a wide variety of Candida infections in the biliary tract, but this is the first discussion of cholecystitis caused by Candida without confounding factors such as biliary calculi or multiple pathogens. After the discussion of our patient's case, we also reviewed the English-language literature regarding candidal AAC and discussed diagnosis, treatment, and mortality.

Diagnostic accuracy of computed tomography imaging of surgically treated acute acalculous cholecystitis in critically ill patients.

BACKGROUND: Acute acalculous cholecystitis (AAC) is a potentially fatal condition mainly affecting critically ill patients. Current experience from computed tomography (CT) findings in AAC is contradictory. METHODS: CT images of 127 mixed medical-surgical intensive care unit patients were retrospectively reviewed for the following findings: bile density, thickness and enhancement of the gallbladder (GB) wall, subserosal edema, greatest perpendicular diameters of the GB, width of extrahepatic bile ducts, gas within the GB, ascites, peritoneal fat edema, and diffuse tissue edema. Forty-three of these patients underwent open cholecystectomy, and 8 patients revealed a normal GB, 26 an edematous GB, and 9 a necrotic AAC. RESULTS: Abnormal CT findings were present in 96% of all the intensive care unit patients. Higher bile density in the GB body and subserosal edema was associated with an edematous GB (specificity, 93.6%; sensitivity, 23.1%). The most specific findings predicting necrotic AAC were gas in the GB wall or lumen, lack of GB wall enhancement, and edema around the GB (specificity, 99.2%, 94.9%, and 92.4%, respectively; and sensitivity, 11.1%, 37.5%, and 22.2%, respectively). CONCLUSIONS: The frequency of nonspecific abnormal findings in the GB of critically ill patients limits the diagnostic value of CT scanning in detecting AAC. However, in the case of totally normal GB findings in CT, the probability of necrotic AAC is low.