What Is Acalculous Cholecystitis?

“The signs and symptoms of acalculous cholecystitis are similar to calculous cholecystitis,” says Felipe Boff Maegawa, MD, a surgeon at Emory Healthcare in Atlanta who specializes in procedures related to the liver, bile ducts, gallbladder, and pancreas.

Other symptoms include:

• Nausea and vomiting
• Fever
• Upper abdominal pain
• Food intolerances, bloating, and belching

In many cases, patients with acalculous cholecystitis have been in the hospital for other significant illnesses or are recovering from major surgery.

“Patients who are very sick [with acalculous cholecystitis] can also be ‘septic,’” where they have dangerously low blood pressure due to infection,” says David Diehl, MD, a gastroenterologist and clinical professor of medicine and pathology at Geisinger Commonwealth School of Medicine in Danville, Pennsylvania.

Some surgeries can disrupt normal blood flow to the gallbladder, causing ischemia (a reduction in blood supply). A major operation may also introduce bacteria into the bloodstream and increase the risk of a gallbladder infection.

Dr. Maegawa lists the following as factors that may raise the risk of getting acalculous cholecystitis:

• Major surgery
• Trauma
• Burns
• Sepsis caused by bacterial, fungal, viral, or parasitic infections
• Critical illness requiring intensive care
• Total parenteral nutrition (TPN), in which nutrients are provided directly into the bloodstream through an IV
• Prolonged fasting, which along with TPN can create a slowing of fluids in the gallbladder and negatively effect the composition of bile
• Immunodeficiency (in HIV and transplant patients, for example)
• Chronic illnesses such as diabetes, hypertension, obesity, renal (kidney) failure, and atherosclerosis

“Diagnosis is usually difficult because the critically ill patients are not able to cooperate, as they are sedated, intubated, and unconscious,” says Maegawa.

The diagnostic process might involve:

• A clinical evaluation of a patient’s symptoms, followed by a blood test to see if there is an elevated white blood count or another indication of abnormal liver function

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• Imaging via ultrasound (or possibly X-ray or computed tomography scan) to see if there is a thickening of the gallbladder walls or other signs of inflammation
• A detailed specialized scan, such as a HIDA (hepatobiliary iminodiacetic acid) scan, to check for abnormal movements (contractions) of the gallbladder and blocked bile ducts

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• PTC (percutaneous transhepatic cholangiography), a test that involves injecting a dye into the bile ducts so images may be more clearly viewed on X-rays
• ERCP (endoscopic retrograde cholangiopancreatography), which uses X-rays and a long, flexible tube (endoscope) with a light and camera at one end to provide a view of the bile ducts
• MRCP (magnetic resonance cholangiopancreatography), which offers detailed imaging of the liver, pancreas, gallbladder, and bile drainage area

There are a number of different approaches for recovering from acalculous cholecystis. Note that most treatments also involve limiting food, since digestion can slow healing.

Medication Options

• Antibiotics: Dr. Diehl calls antibiotics “the cornerstone of therapy.” They are often administered intravenously.

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• Fluids and pain medications: These can ease symptoms and help with healing.

Surgery and Procedures

• Percutaneous cholecystostomy: The insertion of a drainage tube relieves pressure and helps clear infection.
• Cholecystectomy: In some cases, a surgeon will remove the gallbladder. Diehl stresses that doctors typically try to avoid this because patients with acalculous cholecystitis usually also have another severe medical condition that makes surgery risky. Under normal conditions, gallbladder removal is considered a safe procedure; the body adjusts as bile simply flows directly into the small intestine from the liver.

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To help lower the chances of developing acalculous cholecystitis, Maegawa notes the importance of a healthy, active lifestyle and the importance of closely managing any chronic conditions you may have.

“Conditions such as diabetes, hypertension, atherosclerosis, obesity, and HIV can increase the risk of the development of acalculous cholecystitis in the event of critical illness,” he says.

• Long periods of fasting
• Total parenteral nutrition
• Drastic weight loss

If not treated promptly, the disease can lead to:

• Death of gallbladder tissue (gangrenous cholecystitis): This can cause a severe infection that could spread throughout the body.
• Gallbladder splitting open (perforated gallbladder): This also can spread the infection within your gut or lead to a buildup of pus (abscess).

The disease has an incidence rate of 0.12 percent in the entire population.

Acalculous cholecystitis is often related to other medical conditions, particularly those affecting the gallbladder or those that cause systemic inflammation or decreased blood flow to the gallbladder.

• Systemic infections
• Critical illnesses
• Major trauma or surgery
• Prolonged fasting
• Liver diseases
• Diabetes
• Immunocompromised states
• Certain cancers

• Acalculous cholecystitis is a rare and life-threatening type of gallbladder infection that does not involve the presence of gallstones.
• The disease can develop in patients who have other significant illnesses or are recovering from major surgery.
• Acalculous cholecystitis can be difficult to diagnose, but the sooner it is identified and treated, the better the odds are of survival.