Acute Cholecystitis in Critically-Ill Patients

Abstract

Acute de novo cholecystitis occur in 0.2 to 1% of critically-ill patients and is associated with several risk factors (fasting, parenteral nutrition, mechanical ventilation, circulatory failure, severe burns, catecholamines) leading to ischemia-reperfusion of the gallbladder (GB) wall and to a typical acalculous cholecystitis. However, recent data find the presence of gallstones in about half of the cases. This disease has a high mortality around 40% because of its severity and the challenge to confirm the diagnosis. In these critically-ill patients, there are no strict clinical or biological criteria to confirm diagnosis. Abdominal imagery may be misleading because of the confounding factors usually found in critically-ill patients; the most suggestive signs are GB wall thickening greater than 4 mm, enlarged GB size, or a lack of GB wall enhancement. Emergency treatment involves broad-spectrum antibiotics to target digestive and nosocomial germs and hemodynamic optimization. Laparoscopic cholecystectomy (or even subcostal cholecystectomy) is the gold-standard treatment to avoid recurrence. However, because of the severity of the patients, cholecystostomy is frequently preferred. Percutaneous drainage is an interesting alternative treatment because of its availability and its effectiveness. However, there is a theoretical risk of recurrence after removal of the drain, especially in case of calculous cholecystitis. Internal GB drainage with an endoscopic approach (transpapillary or transdigestive) is a hopeful option but currently restricted to specific centers.