Acalculous cholecystitis
Reviewed and revised 5/5/12
OVERVIEW
- often complication of various conditions
- high incidence of gangrene -> perforation
- high mortality & morbidity
- pathophysiology: bile stasis + increased viscosity c/o fever, dehydration, no enteral feeding -> CCK induced gall bladder contraction with wall ischaemia
CLINICAL FEATURES
- new sepsis or shock
- variable signs
- abdominal pain
- RUQ pain
- Murphy’s sign positive
- icterus
Risk Factors
- critically ill (mechanical ventilation, sepsis, burns, trauma)
- HIV
- TPN
- pregnancy -> prolonged labour
- DM
- major surgery
- vasculitis
INVESTIGATIONS
Laboratory
- leucocytosis
- hyperbilrubinaemia
- increased ALP
- transaminitis
- positive blood cultures
Imaging
- US: distended acalculous gall bladder, thickened wall, pericholic fluid
- CT: above changes
- Hepatobillary Imino-Diacetic Acid scan (HIDA)
— nuclear imaging procedure -> Technetium-99m IV -> uptake in GB should take place in 1 hour, if not -> cholecystitis/cystic duct obstruction (used if diagnosis uncertain)
MANAGEMENT
Resuscitation
- A and B – often intubated and ventilated for primary pathology
- C – support shock with fluids and vasoactives
- early broad-spectrum antibiotic coverage: Cefuroxime + Metronidazole
Acid-Base and Electrolytes
- proportional to shock
Specific Treatment
- early surgical consultation if rapidly deteriorating and perforated
- drainage (percutaneous) – U/S or CT
- cholecystectomy
- NBM
Underlying Cause
- treat underlying illness
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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