Q: 52 year old diabetic male with now resolving sepsis (off pressors) found to develop severe right upper quadrant (RUQ) tenderness around 7 PM. STAT ultrasound showed distended acalculous gallbladder with thickened walls (4 mm). Diagnosis of Acalculous Cholecystitis made. Time is now 10 PM. Your next step should be:

A) Make patient NPO. Follow-up with LFT (Conservative approach)

B) Make patient NPO. Start Antibiotics and call surgery in the morning

C) Make patient NPO. Start Antibiotics and call STAT Surgical consult

D) Call interventional Radiology to perform percutaneous cholecystostomy

E) Call GI service to perform endoscopic gallbladder stent placement



Answer: C

When the diagnosis of acalculous cholecystitis is established, immediate intervention is indicated because of the high risk of rapid deterioration and gallbladder perforation. The definitive treatment of acalculous cholecystitis is cholecystectomy (open or laparoscopic).

In patients who are not surgical candidates, percutaneous cholecystostomy may be performed in the interventional radiology as an alternative. Catheters are usually removed after approximately 3 weeks in critically ill patients with acalculous cholecystitis who have undergone percutaneous cholecystostomy. This allows for the development of a mature track from the skin to the gallbladder.

In patients who get declared non-surgical cases, endoscopic gallbladder stent placement has been reported as an effective palliative treatment. This involves placement of a double pigtail stent between the gallbladder and the duodenum during endoscopic retrograde cholangiopancreatography (ERCP).