Therapy

There is still some debate about the appropriate therapeutic approach to patients with acute acalculous cholecystitis. Although patients have been successfully observed with supportive therapy only, there have also been reports of failure of conservative therapy. Percutaneous non-transhepatic and transhepatic cholecystostomy under ultrasound guidance has been used with some success; however, a mortality of up to 10 per cent has been reported. Owing to the lack of correlation between symptomatology and pathology, and the high incidence (59 per cent) of necrosis or gangrene on pathological review of the gallbladder wall, cholecystectomy is the definitive procedure of choice. The use of laparoscopy in the ICU is inviting; however, it has not been critically analyzed. Nonetheless, owing to the presence of necrosis or gangrene in a significant number of patients and the lack of correlation of physical findings with the presence of acute acalculous cholecystitis, removal of the gallbladder, if feasible, is the safest option. Bibliography

Barie, P.S. and Fischer, E. (1995). Acute acalculous cholecystitis. Journal of the American College of Surgeons, 180, 232-44.

Jennings, W.C., Drabek, G.A., and Miller, K.A. (1992). Significance of sludge and thickened wall in ultrasound evaluation of the gallbladder. Surgery, Gynecology and Obstetrics, 174, 394-8.

Kurzweil, S.M., Shapiro, M.J., Andrus, C.H., Wittgen, C.M., Herrmann, V.M., and Kaminski, D.L. (1994). Hyperbilirubinemia without common bile duct abnormalities and hyperamylasemia without pancreatitis in patients with gallbladder discase. Archives of Surgery, 129, 829-33.

Shapiro, M.J., Luchtefeld, W.B., Kurzweil, S., Kaminski, D.L., Durham, R.M., and Mazuski, J.E. (1994). Acute acalculous cholecystitis in the critically ill. American Surgeon, 60, 335-9.

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