Acalculous cholecystitis is more deadly than gallstones

Acalculous cholecystitis-Overview

Acalculous cholecystitis (ACC) is severe gallbladder inflammation without gallstones. Prolonged fasting, serious illnesses (like major burns, infections, or severe injuries), total parenteral nutrition (TPN), and poor blood flow to the gallbladder can lead to ACC, unlike the more common type of cholecystitis, which happens when a gallstone blocks ACC is more deadly than gallstone-induced cholecystitis and can cause perforation and gangrene.

What Makes It Serious

• No Gallstones, High Risk: This kind of cholecystitis lacks gallstones, making it harder to detect and sometimes missed.
• Gallbladder perforation, tissue death, and sepsis can develop swiftly.
• High ICU Mortality: Patients hospitalized for trauma, burns, stroke, or major surgery have a 30% mortality rate.
• Subtle symptoms: In ventilated or comatose patients, fever may be the only sign.

Those Most at Risk

• After major surgery, patients
• Sepsis, burns, and trauma patients
• Total parenteral nutrition or extended fasting
• People with HIV or vascular illness

Pathophysiological Foundations

• Ischemia:  lowers gallbladder blood flow, particularly in hypotension or shock.
• Cholestasis: Fasting, TPN, or ileus-induced bile stasis increases pressure and inflammation.
• Infection: E. coli, Klebsiella, Enterococcus secondary infection
• Gallbladder Unrest: Bile stagnation and irritation result from poor contraction.

Common Risks

• Diseases, including sepsis, trauma, burns, and stroke
• Long-term fasting or TPN
• Mechanical ventilation or major surgery
• Chemotherapy, HIV/AIDS immunosuppression
• Cardiovascular or diabetic disease
• Hepatitis A, CMV, and Cryptosporidium in immunocompromised patients

Rare Triggers

• Dissection of the aorta during pregnancy and postpartum.
• Dehydration or electrolyte imbalance,

Key Symptoms of Acalculous Cholecystitis

• Right upper abdominal ache
• Fever
• Nausea, vomiting
• Positive Murphy’s sign
• Bloating, belching
• Post-fatty meal pain
• Hypotension, sepsis

Clinical Signs in Sedated or ICU Patients

• Fever of unknown cause
• Leukocytosis
• Enhanced liver enzymes
• Gallbladder wall thickening on imaging
• Ultrasound shows no gallstones
• These signals may be the only indications of discomfort in patients who cannot speak.

Overview of Diagnostic Criteria

An organized overview based on clinical guidelines.

1. Clinical Presentation

• Undiagnosed fever
• Right upper quadrant discomfort
• Nausea, vomiting
• Positive Murphy's sign (conscious patient)
• Sepsis symptoms without a cause

2. Laboratory Results

• High white blood cell count
• ALT, AST, and ALP are slightly higher
• Sometimes elevated bilirubin
• Procalcitonin or CRP elevation

3. Imaging Criteria

• First-line ultrasound:
• >3 mm gallbladder wall thickening
• Pericholecystic fluid
• Distended gallbladder
• No gallstones
• Murphy's sonogram

A CT scan reveals gallbladder edema.

• Pericholecystitis
• Gas in the wall (emphysematous alterations)
• Stable HIDA scan:
• Lack of gallbladder visibility (cystic duct occlusion)

4. Risky Context: This diagnosis is more prevalent in patients with:

• Has the patient recently undergone surgery or experienced trauma?
• Multiple organ failure, sepsis, burns
• Prolonged fasting or TPN Immunosuppression

Clinical Pearl

• Unexplained fever or sepsis in ICU patients should induce imaging even without stomach pain since symptoms may be hidden.

What treatments are prevalent for this condition?

Acalculous cholecystitis can cause gallbladder perforation, sepsis, and mortality, especially in critically unwell patients, so treatment must be fast and planned. An organized summary of the most frequent and evidence-based options:

The video explains the most common treatments for ACC

Initial Medical Care

• IV broad-spectrum antibiotics:  Target enteric and biliary pathogens (E. coli, Klebsiella, Enterococcus)
• Supportive care: Fluid resuscitation, electrolyte balance correction, and hemodynamic stabilization

Final Interventions

• Surgical candidates, Laparoscopic or open cholecystectomy, Treatment gold standard
• Patients at high risk/non-surgical Cholecystostomy percutaneously Image-guided gallbladder drainage
• In some cases, Gallbladder stenting with ERCP, End-stage liver disease, or coagulopathy palliation

Emerging Advanced Endoscopic Options

• Some high-risk patients prefer EUS-GBD for percutaneous drainage.
• ET-GBD is evaluated when ERCP is already indicated for other reasons.

Monitoring & Following

• Imaging regularly to check the resolution
• Examine for problems or recurrence.
• Consider a delayed cholecystectomy if deferred.

These therapies may cause problems.

Especially as acalculous cholecystitis treatment decisions often include extremely sick patients with little room for error. The complications of medical and interventional therapies are listed here:

• Problems with Medical Management and Treatment: Possible Issues
• Broad-spectrum antibiotics: allergy, resistance, Clostridioides difficile.
• Fluid and nutrition support, Overhydration, electrolyte imbalance, delayed diagnosis

Interventional complications

1. Cholecystectomy

• Blood or bile duct damage
• Infection after surgery
• Anesthesia dangers (particularly in unstable individuals)
• Change from laparoscopic to open surgery due to irritation or adhesions

2. Percutaneous 

• Cholecystostomy: Blockage or dislodging of the catheter
• Abscess or infection locally
• Bile leakage/peritonitis
• Late decisive surgery may be needed.

3. Endoscopic gallbladder drainage

• Obstruction or migration of the stent
• Blood or perforation
• ERCP-related pancreatitis
• Repeat the steps needed. 

Long-term risks

• Recurrence of cholecystitis without gallbladder removal
• Fibrosis or chronic inflammation
• Gallbladder perforation or gangrene from delayed or insufficient treatment

Acalculous cholecystitis therapy

Acalculous cholecystitis can cause perforation, gangrene, and sepsis, so treatment must be timely and tailored to clinical stability. This clinical guideline-based summary is structured.

First Medical Treatment

IV broad-spectrum antibiotics Target enteric and biliary pathogens (e.g., E. coli, Klebsiella, and Enterococcus). Third-generation cephalosporins, metronidazole, and piperacillin-tazobactam are common.

Supportive treatments include resuscitation, electrolyte correction, and hemodynamic stabilization.

Final Interventions

• Notes: Patient Profile, Preferred Treatment
• Stable surgery candidate, Laparoscopic or open cholecystectomy, Absolute best; eliminates inflammation
• Patient at high risk of instability. Cholecystostomy percutaneously, Image-guided drainage; temporizing
• Select palliative cases. Gallbladder stenting with ERCP for Patients with end-stage liver disease or coagulopathy

Emerging Advanced Endoscopic Options

• Some high-risk patients prefer EUS-GBD for percutaneous drainage.
• Transpapillary drainage is used when ERCP is indicated or in patients with high-volume ascites.

Monitoring and Following Up

• Repeat imaging to verify resolution.
• Check for problems or recurrence.
• Initially deferred cholecystectomy? Consider delayed

Clinical Insight

Compared to gallstones, acalculous cholecystitis is caused by ischemia. Cholecystitis is caused by ischemia, bile stasis, and infection, which can be particularly harmful to fragile patients; therefore, it requires immediate treatment with antibiotics, drainage, and possibly surgery.

Also, read https://www.icliniq.com/articles/gastro-health/acalculous-cholecystitis.

What if cholecystitis goes untreated?

Untreated calculous or acalculous cholecystitis can lead to life-threatening consequences. Structured breakdown of what can happen:

Immediate threats and complications

• Gangrenous gallbladder: Tissue death from insufficient blood supply may rupture.
• Perforated gallbladder: A gallbladder wall tear that leaks bile into the abdomen
• Peritonitis: Life-threatening abdominal lining infection
• Sepsis: Multi-organ failure from systemic infection
• Empyema Gallbladder pus needs immediate draining.

Delayed or Chronic Effects

• Chronic cholecystitis: Recurrent inflammation causes fibrosis and gallbladder dysfunction.
• Biliary blockage: Causes jaundice, liver damage, and cholangitis
• If pancreatic duct irritation spreads,
• Digestive issues: Chronic bloating, nausea, and fatty food intolerance

Acalculous cholecystitis can be quiet but dangerous in critically unwell individuals, with up to a 30% death risk due to rapid progression to gangrene or sepsis if left untreated.

Conclusion

 Acalculous cholecystitis, a severe, underdiagnosed gallbladder inflammation without gallstones, affects critically ill or immunocompromised patients. It carries a high risk of complications—including gangrene, perforation, and sepsis—with mortality rates up to 30% in ICU settings. Prompt treatment—ranging from antibiotics and supportive care to percutaneous drainage or surgery—is essential to prevent life-threatening outcomes.