Internal Medicine

0521779407-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:45

Acute Acalculous Cholecystitis 17

■Insidious presentation in already critically ill pts

■Elderly

■Male predominance (80%)

Signs & Symptoms

■Clinical presentation variable, depending on predisposing condi-

tions

■RUQ pain absent in 75% of cases

■Fever or hyperamylasemia may be only clue

■Unexplained sepsis w/ few early localizing signs

■Half of patients already have experienced complication: gangrene,

perforation, abscess

■RUQ pain, fever, & positive Murphy sign seen in minority

tests

Laboratory

■Leukocytosis w/ left shift in 70–85%

■Hyperamylasemia common

■Abnormal aminotransferases, hyperbilirubinemia, mild increase in

serum alkaline phosphatase more common in acalculous than cal-

culous cholecystitis

Imaging

■Plain x-ray: exclusion of a perforated viscus, bowel ischemia, or renal

stones

■US: absence of gallstones, thickened gallbladder wall

➣(>5 mm) w/ pericholecystic fluid, failure to visualize

➣gallbladder, perforation w/ abscess, emphysematous cholecy-

stitis; sensitivity of 36–96%; high false-negative rate

■CT: thickened gallbladder wall (>4 mm) in absence of ascites or hy-

poalbuminemia, pericholecystic fluid, intramural gas, or sloughed

mucosa; superior to US w/ sensitivity of 50–100%

■Radionuclide cholescintigraphy (HIDA) scan: failure to opacify

gallbladder; sensitivity almost 100%; false-positive rate of up to 40%

in which gallbladder not visualized in spite of nonobstructed cystic

duct seen in severe liver disease, prolonged fasting, biliary sphinc-

terotomy, hyperbilirubinemia; important not to allow test to delay

treatment in very ill pts

differential diagnosis

■Calculous cholecystitis, peptic ulceration, acute pancreatitis, right-

sided pyelonephritis, hepatic or subphrenic abscess