Colecistitis acalculosa

Antecedentes

• Enfermedad necroinflamatoria aguda de la vesícula biliar con patogénesis multifactorial
  • Estasis y isquemia de la vesícula biliar llevan a la distensión y eventualmente a la necrosis/perforación
  • Representa el 10% de la colecistitis aguda; se asocia con alta morbilidad/mortalidad

Anatomía y Fisiopatología

• Los cálculos biliares se clasifican como piedras de colesterol y piedras pigmentadas (negras y marrones), y están presentes en aproximadamente el 20% de las mujeres y el 8% de los hombres en los Estados Unidos
• Estas piedras causan la mayoría de todos los problemas de las vías biliares, y dependiendo de dónde se impacte la piedra, ocurren problemas específicos.
• La bilis fluye hacia afuera de la vesícula biliar, por el conducto cístico hacia el conducto biliar común, y finalmente hacia la primera porción del duodeno.

Gallbladder disease types

Gallbladder anatomy (overview).

Gallbladder anatomy

Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.

• Symptomatic cholelithiasis (biliary colic)
• Choledocholithiasis
• Acute calculous cholecystitis
• Ascending cholangitis
• Acalculous cholecystitis
• Biliary atresia
• Cholestasis of pregnancy

Risk Factors

• Burns
• CAD
• DM
• Immunosuppression
• Infection
• Mechanical ventilation
• Medications (eg, opioids, sunitinib)
• Multiple transfusions
• Nonbiliary surgery
• Sepsis/hypotension
• Vasculitis
• TPN, especially TPN > 3 mo

Clinical Features

• Similar to calculous cholecystitis
• Jaundice is common (20% of patients)

Differential Diagnosis

RUQ Pain

• Gallbladder disease
  • Symptomatic cholelithiasis (biliary colic)
  • Choledocholithiasis
  • Acute cholecystitis
  • Ascending cholangitis
  • Acalculous cholecystitis
• Pancreatitis
• Acute hepatitis
• Pancreatitis
• GERD
• Appendicitis (retrocecal)
• Pyogenic liver abscess
• Bowel obstruction
• Cirrhosis
• Budd-Chiari syndrome
• GU
  • Pyelonephritis
  • Kidney stone
  • Fitz-Hugh-Curtis Syndrome
• Other
  • Hepatomegaly due to CHF
  • Peptic ulcer disease with or without perforation
  • Pneumonia
  • Herpes zoster
  • Myocardial ischemia
  • Pulmonary embolism
  • Abdominal aortic aneurysm

Evaluation

Longitudinal ultrasound of gallbladder with thickened wall and mild pericholecystic fluid (arrows). The common bile duct was normal (not shown).

CT showing gallbladder wall thickening and pericholecystic liquid, without gallbladder lithiasis.

Work-Up

• CBC
• Chemistry
• LFTs
• Blood cultures
• RUQ Ultrasound

Diagnosis

• CBC
  • Leukocytosis (70-85% of patients)
• LFTs
  • Hyperbilirubinemia
  • Mildly elevated alkaline phosphatase
  • Transaminitis
• RUQ Ultrasound
  • Absence of gallstones or sludge
  • Thickened wall (>5 mm) with pericholecystic fluid
  • Positive sonographic Murphy's sign
  • Emphysematous cholecystitis with gas bubbles arising in fundus of gallbladder
  • Frank perforation of gallbladder with associated abscess formation

Management

• Antibiotics
  • Ceftriaxone + metronidazole OR
  • Piperacillin/tazobactam
• Cholecystectomy
  • Definitive therapy

Disposition

• Admit

See Also

• Gallbladder Disease (Main)

References