CURRENT Essentials of Critical Care.pdf

Chapter 11 Gastrointestinal Disease 161■■■Acalculous CholecystitisEssentials of Diagnosis• Acute inflammation and necrosis of gallbladder with unexplainedfever, leukocytosis, vague abdominal or right upperquadrant pain; often insidious onset in susceptible patient• Right upper quadrant abdominal tenderness highly variable;mass in 20%; jaundice, positive Murphy sign• Leukocytosis, elevated bilirubin, alkaline phosphatase, aminotransferases• Thickening of gallbladder wall, pericholecystic fluid, absenceof gallstones on abdominal ultrasound; positive ultrasonographicMurphy sign; sometimes may fail to visualize gallbladder• Severe cases with emphysematous cholecystitis, perforationwith abscess formation• Predisposing conditions: critical illness, especially with hypotension,sepsis, postoperative, immunosuppression, total parenteralnutrition, diabetes, biliary surgery; may have no predisposingfactors• Caused by combination of bile stasis, ischemia, local inflammation;part of multiorgan failure in ICU patientsDifferential Diagnosis• Calculous cholecystitis• Acute pancreatitis• Pyogenic hepatic, subphrenic, or intra-abdominal abscess• Ascending cholangitisTreatment• Antibiotics directed against enteric pathogens and anaerobes(ampicillin, aminoglycoside, metronidazole)• Cholecystectomy (open or laparoscopic); laparoscopic preferredin critically ill patients• Drain abscesses■ PearlIn patients too ill to undergo surgery, temporizing strategies with antibioticsand percutaneous drainage until more stable for cholecystectomymay be useful.ReferenceMcChesney JA et al: Acute acalculous cholecystitis associated with systemicsepsis and visceral arterial hypoperfusion: a case series and review of pathophysiology.Dig Dis Sci 2003;48:1960. [PMID: 14627341]