What is Acalculous Cholecystitis?
Acalculous cholecystitis is a specific type of gallbladder inflammation that happens due to a poorly functioning gallbladder that doesn’t empty properly. This is a bit different from the more common cholecystitis, where the gallbladder’s exit tube gets physically blocked, typically by a gallstone. Acalculous cholecystitis was first identified in 1844 by Duncan.
While acute episodes can happen, acalculous cholecystitis generally develops more subtly. It is a more frequent occurrence in patients who are critically ill and staying in intensive care units (ICUs). It’s important to know that acalculous cholecystitis is more than just uncomfortable – it is a serious, life-threatening condition that carries a higher risk of causing the gallbladder to rupture or to die off (necrosis) compared to the common gallstone-related disease.
What Causes Acalculous Cholecystitis?
Gallbladder problems can be triggered by diverse factors. Going without food for a long time, receiving nutrition through a vein (total parenteral nutrition), or losing a lot of weight rapidly can all increase the possibility of gallbladder inflammation without gallstones, referred to as acalculous cholecystitis. It’s common for this condition to exist alongside more serious health concerns.
Patients in critical care, or those recovering from significant surgeries or conditions like stroke, heart attack, severe infections, serious burns, or major injuries, have a higher risk of developing acalculous cholecystitis. If the gallbladder isn’t stimulated to empty, it delays the flow of digestive juices called bile salts, building up pressure within the gallbladder. This can result in limited blood supply, tissue damage due to pressure, and eventual rupture. This stagnant state also encourages the growth of harmful bacteria like Escherichia coli, Klebsiella, Bacteroides, Proteus, Pseudomonas, and Enterococcus faecalis.
People with a long-term condition of acalculous cholecystitis may experience poor gallbladder emptying, known as hypokinetic biliary dyskinesia. Various factors could lead to this, including hormone-related issues, inflammation of blood vessels, and decreased nerve function due to conditions like diabetes. Often the precise cause of chronic acalculous cholecystitis isn’t known.
Risk Factors and Frequency for Acalculous Cholecystitis
Acalculous cholecystitis is a condition that makes up 10% of all acute cholecystitis cases and 5% to 10% of all cholecystitis cases. It affects both males and females equally. However, men are more likely to develop this condition following surgery. People with HIV or other conditions that weaken the immune system are also more likely to get this disease. Acalculous cholecystitis can be caused by different infections that are more common in people with weak immune systems, including microsporidia, cytomegalovirus (CMV), and Cryptosporidium. These infections can thrive in the gallbladder. People who carry Giardia lamblia, Helicobacter pylori, and Salmonella typhi are also at a higher risk of getting cholecystitis.
Signs and Symptoms of Acalculous Cholecystitis
Mild acalculous cholecystitis, a condition involving inflammation of the gallbladder without stones, can have symptoms similar to calculous cholecystitis, which is inflammation with gallstones. Symptoms may include pain in the right upper part of the abdomen, which could be felt more when pressing deeply into this area. This is often referred to as Murphy’s sign. Patients might also feel nauseous, have difficulty tolerating certain foods, experience bloating, and belch more frequently.
Acute acalculous cholecystitis, the severe form of this condition, typically begins with a sudden onset of extreme right upper abdominal pain. In severe cases, doctors may be able to feel an enlarged gallbladder. Patients with this severe form are very sick, may show signs of infection, and are often in the intensive care unit (ICU) because of other serious illnesses or recovering from major surgery. It’s also common, but not always the case, for these patients to have a higher-than-normal white blood cell count, which is a sign of an infection in the body.
Testing for Acalculous Cholecystitis
If a person suffers from chronic acalculous cholecystitis, which is a condition of the gallbladder, the best test to confirm this is a cholescintigraphy nuclear scan, also known as a HIDA scan. This specialized test involves administration of a radioactive substance and a hormone known as cholecystokinin (CCK) to check how well the gallbladder is functioning. CCK causes the gallbladder to empty, and if it releases 35% or less of its liquid content, it may mean the gallbladder isn’t functioning well.
Additionally, an ultrasound of the gallbladder can provide useful information. If it reveals that the wall of the gallbladder is more than 3.5 mm thick, it could suggest an inflammation of the gallbladder, known as cholecystitis.
While blood tests alone cannot confirm this condition, abnormal results such as a high white blood cell count and improper liver function could lend support to the diagnosis.
When it comes to diagnosing acute acalculous cholecystitis, a sudden inflammation of the gallbladder, an ultrasound of the abdomen is often sufficient. This can reveal a noticeably thickened gallbladder wall, swelling, and possibly fluid build-up around the gallbladder. A CT scan can also help make the diagnosis clearer.
If the diagnosis still seems uncertain, a HIDA scan can be performed. In the case of acute cholecystitis, the gallbladder will not show any of the radioactive substance that was administered for the scan.
Treatment Options for Acalculous Cholecystitis
Patients suffering from acalculous cholecystitis, a severe gallbladder condition, need to be stabilized before any treatment can be performed. If the patient’s condition is unstable, doctors might place a tube inside the gallbladder to drain it (percutaneous drainage) or use a special procedure called ERCP to ease the pressure in the gallbladder.
Just like cholecystitis with gallstones, chronic acalculous cholecystitis is typically treated via a laparoscopic cholecystectomy, in which doctors remove the gallbladder through several small incisions. In cases where laparoscopic surgery can’t be done, doctors perform an open cholecystectomy, a procedure that involves a larger incision.
Acute cholecystitis needs to be treated quickly because it can worsen rapidly if left unaddressed. The preferred treatment is to surgically remove the gallbladder, either through laparoscopic or open surgery. However, if the patient cannot withstand a major surgery, a tube may be put in to drain the gallbladder, with the surgical removal postponed till the patient is more stable.
Though broad-spectrum antibiotics are typically given, their effectiveness is usually limited as they struggle to penetrate a pressurized gallbladder. Nonetheless, antibiotics can help treat any spread of bacteria in the blood.
What else can Acalculous Cholecystitis be?
- Cholangitis (inflammation of the bile duct)
- Acute cholecystitis (sudden inflammation of the gallbladder)
- Pancreatitis (inflammation of the pancreas)
- Hepatitis (inflammation of the liver)
What to expect with Acalculous Cholecystitis
Acalculous cholecystitis is a severe condition with a high sickness and death rate. The death rate for this condition can vary from 30% to 50% depending on the patient’s age. Even those who survive tend to have a long recovery period which could last for several months.
Possible Complications When Diagnosed with Acalculous Cholecystitis
Possible complications related to the gallbladder can occur, such as:
- Perforation of the gallbladder
- Gangrene of the gallbladder
- Sepsis, a life-threatening infection that can spread throughout your body
Recovery from Acalculous Cholecystitis
Most patients are advised not to eat or drink until their health condition improves. Therefore, it’s necessary to keep them hydrated through an intravenous (IV) drip.
