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Acalculous Cholecystitis

Leyla Azmoun, MD
Piran Aliabadi, MD
B Leonard Holman, MD

November 14, 1995

Presentation

A 72-year-old diabetic woman presented to the emergency room with colicky right upper quadrant (RUQ) pain and vomiting. She had a low-grade fever and moderate RUQ tenderness on physical examination. Laboratory evaluation was remarkable with a white blood count (WBC) of 14 K/ml.

Imaging Findings

Ultrasonography
Hepatobiliary scintigraphy

Except for diffuse vascular calcification and mild cardiac enlargement, chest x-ray and KUB were unremarkable.

Abdominal ultrasound demonstrates echogenic sludge within a moderately distended gallbladder (arrow). No discrete gallstone is visible. The gallbladder wall is not thickened (arrow). There is no biliary ductal dilatation.

Serial images from a Tc-99m-IDA scan show normal hepatic uptake of radiotracer with normal visualization of common duct (arrow) and bowel (arrow) at 30 minutes after injection. The gallbladder is not visualized at 1 hour despite an intravenously administered dose of morphine sulfate.

These findings are diagnostic of acute acalculous cholecystitis.

Diagnosis

Acute acalculus cholecystitis

Discussion

In 85% of patients, acute cholecystitis is due to obstruction of the cystic duct by a gallstone. Only 15% of patients with cholecystitis have no gallstones by ultrasound or pathology. Factors predisposing to acalculus cholecystitis include prolonged fasting, chronic infection and ischemia. Radionuclide hepatobiliary imaging is highly sensitive (95%) and specific (99%) for diagnosing acute cholecystitis. Since it is not as sensitive as ultrasound for making a nonbiliary diagnosis, however, it is often reserved for patients whose sonograms are equivocal for diagnosis of acute cholecystitis.

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