Acalculous cholecystitis

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  • Acute necroinflammatory disease of gallbladder with multifactorial pathogenesis
    • Gallbladder stasis and ischemia leads to distension and eventually necrosis/perforation
    • Accounts for 10% of acute cholecystitis; associated with high morbidity/mortality

Anatomy & Pathophysiology

  • Gallstones are classified as cholesterol stones and pigmented stones (black and brown), and are present in approx 20% of females and 8% of males in the United States
  • These stones cause the majority of all biliary tract problems, and depending on where the stone become impacted, specific problems occur.
  • Bile flows out the gallbladder, down the cystic duct into the common bile duct, and ultimately into the 1st portion of the duodenum.

Gallbladder disease types

Gallbladder anatomy (overview).
Gallbladder anatomy

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

Differential Diagnosis

RUQ Pain



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


  • Leukocytosis (70-85% of patients)
  • LFT abnormalities
    • Hyperbilirubinemia
    • Alk phos elevation (mild)
    • Transaminitis
  • Ultrasound findings:
    • 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



  • Admit

See Also

Gallbladder Disease (Main)