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Acute Acalculous Cholecystitis

George M Wu, MD
Faye C Laing, MD

September 28, 1994

Presentation

A 64-year-old man with a history of non-insulin dependent diabetes mellitus and coronary artery disease presented with right upper quadrant pain.

Imaging Findings

Ultrasound of gallbladder
Color flow Doppler of gallbladder
Hepatobiliary scintigraphy (2 frames per minute)

Ultrasound examination of the abdomen shows a diffusely thickened gallbladder wall (arrow) and a trace amount of free fluid in Morison's pouch. The sonographic Murphy's sign is strongly positive. No stones or biliary sludge are visible in the gallbladder. There is no intrahepatic or extrahepatic biliary duct dilatation, and the ommon duct measures 6.0 mm. The liver, kidneys and pancreas appear normal. Color flow Doppler study of the gallbladder wall demonstrates arterial blood flow coursing around the entire anterior and fundal portions of the gallbladder wall (arrow). Hepatobiliary scintigraphy with Tc99m-IDA shows nonvisualization of the gallbladder with prompt excretion of radio-pharmaceutical via the common duct into the duodenum.

Differential Diagnosis

In a diabetic patient who has a positive sonographic Murphy's sign, thickened gallbladder wall, absent gallstones and sludge, and free fluid in Morison's pouch, acute acalculous cholecystitis has to be considered as the leading diagnosis. The color flow Doppler study demonstrates abnormally increased arterial blood flow to the wall of the gallbladder fundus consistent with acute inflammation. Much less likely would be pancreatitis, hepatitis or hypoalbuminemia causing diffuse thickening of the gallbladder wall. Congestive heart failure is also a cause of gallbladder wall thickening.

Diagnosis

acute acalculous cholecystitis

Discussion

Acute acalculous cholecystitis (AAC) is found in approximately 2-15% of patients undergoing cholecystectomy. Predisposing factors include trauma, mechanical ventilation, hyperalimentation, post-operative state, diabetes mellitus, vascular insufficiency, prolonged fasting, burns, postpartum state, AIDS, and infectious colitis. These conditions share the propensity to produce gallbladder ischemia.

Imaging studies should look for gallbladder wall inflammation and/or cystic duct obstruction. On ultrasound, one should attempt to elicit the sonographic Murphy's sign and look for irregular gallbladder wall thickening, intramural gas, pericholecystic fluid or sloughed mucosa. Using currently available ultrasound equipment, arterial blood flow is frequently seen to the body but not the fundus of a normal gallbladder. Therefore, the visualization of arterial blood flow in the gallbladder fundus with color and duplex Doppler sonography should also be considered as a sign of acute inflammation. Computed tomography (CT) may also show periportal inflammation and gallbladder wall edema. Cholescintigraphy should demonstrate nonvisualization of the gallbladder with a patent common bile duct.

The role of the various imaging modalities in AAC is still somewhat controversial. Mirvis et al. [3] showed that sonography and CT are over 90% specific and sensitive for diagnosing AAC, while cholescintigraphy is highly sensitive but only 38% specific. Others, however, have found neither sonography nor scintigraphy especially sensitive in the diagnosis of AAC.

In patients at risk, color and duplex Doppler study of the gallbladder wall may contribute to the specific diagnosis of AAC by showing abnormally increased arterial blood flow to the gallbladder fundus.

With recent advances in sonographic technology, and because of its relatively lower cost and portability, sonography should be regarded as a satisfactory screening test. Clinicians should have a low threshold of suspicion for AAC in patients with predisposing conditions. Even with early diagnosis and surgery, AAC has an operative mortality of six to seven percent.

References

1. Babb RR. Acute acalculous cholecystitis: a review. J Clin Gastroenterol, 1992;15: 238-241.

2. Cornwell EE III, Rodriguez A, Mirvis SE, Shorr RM. Acute acalculous cholecystitis in critically injured patients. Ann Surg, 1989;210 (1): 52-55.

3. Mirvis SE, Vainright JR, Nelson AW, et al. The diagnosis of acute acalculous cholecystitis: A comparison of sonography, scintigraphy and CT. AJR, 1986;147:1171-1175.

4. Zeman RK. Cholelithiasis and cholecystitis. In: Gore RM, Levine MS, Laufer I, editors. Text of gastrointestinal radiology. Philadelphia: WB Saunders, 1994:1654-55.

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