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Dennis Kim, trauma surgeon and surgical intensivist of the Trauma ICU Rounds podcast, weighs in on the diagnosis and management of acalculous cholecystitis.
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Takeaway pearls
- Acalculous cholecystitis accounts for about 10% of all cholecystitis and occurs almost exclusively in the critically ill. Risk factors include being NPO, TPN use, surgical patients, and critical illness. Enteral feeding is probably rather protective, and maybe even somewhat therapeutic.
- Although data is limited, anecdotally, this disease has become much less common in the modern era, perhaps because we try to feed ICU patients earlier.
- Suspect this diagnosis in a patient with inflammatory features such as fever (often low-grade) not explained by their other illness. Assess for elevations in alk phos or bilirubin, RUQ abdominal tenderness, and imaging abnormalities to unpack it further. Unfortunately, cholestasis alone can often occur in critical illness, making it difficult to differentiate from true cholecystitis.
- CT scan will often be the initial study in complex patients, though RUQ ultrasound can be used if suspicions are more targeted. In general, a high-quality ultrasound is a better study, but CT is more broad, and better than a technically poor ultrasound.
- (No, in this setting, it is not important for patients to be NPO before their ultrasound.)
- Always CT with IV contrast! A non-contrast CT is often very little use; AKI is not a good reason to avoid contrast.
- HIDA scan is a pain to obtain, but is nearly 100% accurate, if other tests are not definitive.
- Gallbladder dilation is fairly non-specific in NPO or ill patients. Thickening or edema still common but more suspicious, stranding more so, and frank perforation, abscess, lack of enhancement (gangrene), or gas are highly specific. (Pericholecystic fluid is obviously only meaningful if generalized ascites is absent.)
- In general, the treatment of choice is percutaneous cholecystostomy. Surgery is usually only desirable if there are more advanced complications, such as perforation or gangrene. In the least severe cases, antibiotics alone can be tried, although most of our patients are already on antibiotics when diagnosed (ie. have already “failed” this approach). It is reasonable to consider availability of resources too; small centers may not have IR available to place a perc chole, for instance.
- Should General Surgery even be involved if IR is simply going to place a tube? Maybe not, unless you’re not sure what to do. But in many centers IR will not be willing to follow these patients after the tube is placed, so Surgery may be needed for the ongoing management, especially once they leave the ICU.
- Should Gastroenterology be involved? Probably not routinely, but these folks are always coming up with new endoscopic maneuvers. There may be patients for whom ERCP could be a sensible therapeutic approach to stent the cystic duct (preferably without sphincterotomy), for instance in a patient too coagulopathic for perc chole, though ERCP in a critically ill patient is not always risk-free either.
- Perc chole will usually treat the disease. But tubes can displace (during placement or later) or get obstructed if not regularly flushed, so keep an eye on them.
- Coagulopathic patients can bleed with perc chole placement, as these usually penetrate the liver parenchyma.
- Unlike calculous cholecystitis treated with perc chole (which usually warrants early transition to surgical cholecystectomy, generally during the same admission), most of these will stabilize with percutaneous drainage alone, and the tube can simply be removed once they’re eating and no longer critically ill. They’re usually left for a minimum of 4-6 weeks to let the tract mature, and before removal, a tube cholecystogram should be done (contrast injected into the tube) to ensure the cystic duct is now patent. There is usually some drainage/leakage after removal, which can irritate the skin, but usually stops on its own.
- Cholecystectomy after perc chole is unfortunately more technically challenging due to distortion of the anatomy.