Acute acalculous cholecystitis in the critically ill

Q: 52 year old diabetic male with now resolving sepsis (off pressors) found to develop severe right upper quadrant (RUQ) tenderness around 7 PM. STAT ultrasound showed distended acalculous gallbladder with thickened walls (4 mm). Diagnosis of acalculous Cholecystitis made. Time is now 10 PM. Your next step should be: (select one)

A) Make patient NPO. Follow-up with LFT (Conservative approach)

B) Make patient NPO. Start Antibiotics and call surgery in the morning

C) Make patient NPO. Start Antibiotics and call STAT Surgical consult

D) Call interventional radiology to perform percutaneous cholecystostomy

E) Call GI service to perform endoscopic gallbladder stent placement

Answer: C

When the diagnosis of acalculous cholecystitis is established, immediate intervention is indicated because of the high risk of rapid deterioration and gallbladder perforation. The definitive treatment of acalculous cholecystitis is cholecystectomy (open or laparoscopic). Surgical consultation takes precedence over any intervention.

In patients who are not surgical candidates, percutaneous cholecystostomy may be performed in interventional radiology as an alternative. Catheters are usually removed after approximately 3 weeks in critically ill patients who have undergone percutaneous cholecystostomy. This allows for the development of a mature track from the skin to the gallbladder.

Also, endoscopic gallbladder stent placement has been reported as an effective palliative treatment. This involves the placement of a double pigtail stent between the gallbladder and the duodenum during endoscopic retrograde cholangiopancreatography (ERCP).

#hepatology

References:

1. Gallaher JR, Charles A. Acute Cholecystitis: A Review. JAMA. 2022 Mar 8;327(10):965-975. doi: 10.1001/jama.2022.2350. PMID: 35258527.

2. Treinen C, Lomelin D, Krause C, Goede M, Oleynikov D. Acute acalculous cholecystitis in the critically ill: risk factors and surgical strategies. Langenbecks Arch Surg. 2015 May;400(4):421-7. doi: 10.1007/s00423-014-1267-6. Epub 2014 Dec 25. PMID: 25539703.