**6. Complications**

Perforations or gangrene of the gallbladder and exstrabiliary abscess formation in the acute alithiasic versus lithiasic gallbladder may occur [14].

#### **7. History and physical Exam**

Often these patients are very seriously admitted to intensive care in mechanical ventilation and cannot participate in an anamnestic interview and therefore communicate their symptoms. Physical examination may detect fever, tenderness on the upper abdominal quadrants of the right associated with laboratory abnormalities such as neutrophil leukocytosis and altered liver tests (high values for ALT, AST, alkaline phosphatase and direct bilirubin) [15].

#### **8. Diagnosis**

The diagnosis of acute cholecystitis acalculous is difficult because no clinical data (symptoms, examination goal, testing laboratory) establish it. Although no combination of clinical factors will lead to the diagnosis, there seems to be a consensus on the fact that a high clinical suspicion for acute cholecystitis acalculous is indicated in all critically ill patients for whom no etiology has been found. The final diagnosis of acute cholecystitis is mainly based on radiological and ultrasound findings [16–18].

#### **9. Radiology**

There is controversy about what is the best imaging modality and which to use in the diagnosis of cholecystitis acute acalculous. However, radiological criteria for the


#### **Table 2.**

*Imaging criteria.*

diagnosis of acute alithic cholecystitis have been developed for the use of ultrasound and computed tomography. MRI is not used because it is a lengthy procedure with no benefit compared to the other modalities [19]. CT offers few advantages over ultrasound abdominal, unless there are other intra-abdominal pathologies that cannot be studied with the ultrasound. Therefore, abdominal ultrasound was the first line for the diagnosis of acute alithiasic cholecystitis as it can be performed at the bedside and favors patients who are intrasportable [20]. The ultrasound criteria for diagnosing acute alithiasic cholecystitis are: the thickness of the gallbladder wall, dangerous cystic fluid, wall, edema intramural gas, desquamated mucosa, mud or hydrops. The thickness of the gallbladder wall (3.5–4 mm) has been considered a crucial component for the diagnosis of acute alithiasic cholecystitis. Therefore, abdominal ultrasound is a very useful tool for diagnosing acute alithiasic cholecystitis as many prospective studies have suggested and, also, it is easy to use, fast, portable and easily repeatable at the bedside [21–23].

CT is useful for diagnosing acute alithiasic cholecystitis and other abdominal diseases. it requires patient transport, which may not be feasible, and offers few advantages compared to abdominal ultrasound. However, with a normal ultrasound, CT can diagnose acute alithiasic cholecystitis and make a differential diagnosis (**Table 2**) [5, 24, 25].

#### **10. Therapy**

The two prevalent treatment options for acute alithiasic cholecystitis are cholecystostomy (gallbladder drainage) and/or cholecystectomy. Other methods such as ERCP using stents or tubes have been tried but unsuccessful. Cholecystectomy is generally considered the definitive therapy. Some authors propose cholecystostomy as the only treatment. Others claim that the cholecystostomy is just a bridge to the cholecystectomy more secure or just a treatment to see if the acute cholecystitis acalculous is resolved. Therefore, Boland et al. recommend the cholecystostomy prophylactic for all intensive care patients with abdominal sepsis who do not improve with medical therapy (high-dose antibiotic therapy) [26, 27].

#### *Acute Alitasic Cholecystitis DOI: http://dx.doi.org/10.5772/intechopen.99188*

The cholecystostomy is generrally plausible, quick and safe; it can be performed transperitoneally or transhepatically under ultrasound or CT guidance by interventional surgeons or radiologists. Therefore, cholecystostomy can provide time to optimize the patient's condition for cholecystectomy surgery. There seems to be an unanimous tendency to favor the cholecystostomy before cholecystectomy, unless there is a strong evidence of an ischemic cholecystitis that the drainage alone does not alleviate.

Cholecystectomy is a definitive therapy when performed by open or laparoscopic surgery. Laparoscopic surgery has been favored in recent years because it can be both diagnostic and therapeutic, it is less invasive, and it has similar morbidity and mortality compared to open procedures [28–31]. However, it should be noted that it may need to be converted to an open cholecystectomy and this should not be considered a failure of the surgeon on the contrary, when faced with situations in which it is not possible to distinguish, due to the inflammatory state of the gallbladder, the various structures anatomical, conversion to "open surgery" is preferable [32–35].
