Acute acalculous cholecystitis


Acalculous cholecystitis is an acute necroinflammatory disease of the gallbladder.

Acalculous gallbladder disease is an inflammation of the gall bladder in the absence of stones.

 Acute cholecystitis and is associated with high morbidity and mortality rates.

Acalculous cholecystitis results from gallbladder stasis and ischemia, which then cause a local inflammatory response in the gallbladder wall. 

The majority of patients with acalculous cholecystitis have multiple risk factors.

The risk of acalculous gallbladder disease is increased with long term illness, severe trauma or a serious medical condition.

Factors associated with a calculus acute cholecystitis include: critical illness, diabetes, HIV infection, atherosclerosis, and total parenteral nutrition.

5 to 10% of patients with acute cholecystitis have acute acalculous cholecystitis.

Specific primary infections predispose to acalculous cholecystitis:

Acquired immunodeficiency syndrome (AIDS) and other immunosuppressed patients may be due to opportunistic infections such as microsporidia, Cryptosporidium, or cytomegalovirus.

Acalculous cholecystitis, leads endothelial injury, gallbladder ischemia, and stasis, and  to concentration of bile salts, gallbladder distension, and eventually necrosis of the gallbladder tissue. 

Once acalculous cholecystitis is established, secondary infection with enteric pathogens, including Escherichia coli, Enterococcus faecalis, Klebsiella spp, Pseudomonas spp, Proteus spp, and Bacteroides fragilis and related strains, is common.

Perforation occurs in severe cases.

AC occurs typically in patients who are hospitalized and critically ill.

Occurs in about 0.2 to 0.4% of all critically ill patients, usually in patients older than 50 years, and at least three times more common in men than women. I

It may also be seen in the outpatient setting in patients with risk factors for acalculous cholecystitis.

it has been reported in 0.7 to 0.9 percent of patients following open abdominal aortic reconstruction, in 0.5 percent of patients following cardiac surgery, and in as many as 4 percent of patients who have undergone bone marrow transplantation.

There is a male preponderance with acute acalculous cholecystitis ranging from 40 to 80 percent.

The symptoms of acalculous gallbladder disease are similar to those of acute cholecystitis that results from gallstones. 

AC can be slowly progressive  with intermittent or vague symptoms. or acute.

The complications of acalculous gallbladder disease can be very severe: it is a potentially life-threatening disorder.

Mild symptoms may include:


Nausea and vomiting

Food intolerance

Severe symptoms may develop abruptly, the onset of severe symptoms may include:

Right upper quadrant abdominal pain.


Symptoms of acute cholecystitis: 

nausea, vomiting, fever, chills, jaundice bloating of the abdomen, pain that typically occurs after a meal.

Distended gallbladder that can be palpated.


In chronic acalculous cholecystitis, symptoms are more prolonged, more intermittent and vague.

Causes of gallbladder dysfunction, common causes include:

Fasting for long periods 

Dramatic weight loss

Long periods of total parenteral nutrition (TPN).

Gallbladder stasis due to a lack of gallbladder stimulation that leads to an increase in the concentration of bile salts and a build-up of pressure in the gallbladder.

Decreased function of gallbladder emptying.

Hypokinetic biliary dyskinesia

Predisposing factors for acalculous gallbladder disease include:

Noninfectious conditions of the liver and biliary tract.

 Acute hepatitis

Wilson’s disease

Gallbladder polyps 

Systemic infectious diseases 

Viral infections such as Ebstein-Barr virus (EBV) or cytomegalovirus

Bacterial infections such as Group B Streptococcus infection

Severe physical trauma such as third-degree burns

Heart surgery

Abdominal surgery


Acalculous gallbladder disease accounts for 10% of all cases of acute inflammation of the gallbladder.

It accounts for 5% to 10% of all cases of non-acute cholecystitis.

The male to female ratio of incidence of acalculous gallbladder disease is between 2 to 1 and 3 to 1.1.

The incidence of acalculous gallbladder disease is higher in those with human immunodeficiency virus (HIV) infection and other illnesses that suppress the immune system.

People that carry Giardia lamblia, Helicobacter pylori, and Salmonella typhi also have an increased risk of developing acalculous gallbladder disease and other forms of inflammation of the gallbladder.

An ultrasound is often used to diagnose acalculous gallbladder disease. 

It may show thickening of the gallbladder wall. 

If the test results from ultrasound are uncertain, the test of choice is a cholescintigraphy nuclear scan (HIDA) with the administration of cholecystokinin (CCK).5

The cells in the liver that produce bile take up the tracer; the tracer then travels into the bile and gallbladder, then finally into the small intestine. 

As the tracer travels through the gallbladder, computer images are taken. 

Cholecystokinin stimulates the gallbladder to empty, and the HIDA scan will show the inability of the gallbladder to effectively empty when acalculous gallbladder disease is present.

Differential Diagnosis

Acute cholangitis 

Acute cholecystitis



Treatment of acalculous gallbladder disease is  dependent  on its severity.

A person who has severe symptoms, such as septicemia will requre reduction in pressure that has built up in the gallbladder with a placement of a drainage tube in the gallbladder.

If a bacterial infection is present, antibiotics are given.

With chronic acalculous gallbladder disease, the gallbladder inflammation is stable, and is managed the same as an inflammation of the gallbladder with cholelithiasis: cholecystectomy.

Acalculous gallbladder disease is a very serious illness that has a high mortality rate.

With acalculous acute cholecystitis ischemia and bile stasis occurs in the gallbladder wall leading to bile insipissation that is is directly toxic to the gallbladder epithelium.

The gallbladder endothelial injury leads to ischemia, hypo perfusion which can occur in critical ill patients.

Acalculous acute cholecystitis could also progress to gangrene, empyema and perforation up to 50% of patients.

Mortality rate for acalculous gallbladder disease once perforation occurs, can be as high as 30%.

2-15% of cases of acute cholecystitis.

Incidence is increasing.

Mortality many times greater than that for calculous disease.

40% of patients undergo rapid progression to gangrene and perforation of the gall bladder.

Mortality ranges from 6%-67%.

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