Acute Alitasic Cholecystitis

*Giovanni Petracca, Francesco Zappia, Maccarone Giuseppe, Mazzeo Mariano, Mio Francesco, Fabrizio Silvaggio, Mileto Ivana, Plutino Francesco, Posterino Antonietta and Danilo Cafaro*

### **Abstract**

Acute acalculous cholecystitis (AAC) is the inflammatory disease of the gallbladder in the absence of gallstones. Typically affects critically ill patients. Diagnosis is not straightforward as Murphy's sign is difficult to detect in critically ill and many imaging findings are numb or nonspecific. Acalculous cholecystitis is a life-threatening disorder that has a high risk of perforation and necrosis compared to the more typical calculous disease. Management involves a percutaneous cholecystostomy, a surgical cholecystectomy, or, more recently, a metal stent placed endoscopically through the gastrointestinal tract into the gallbladder. Acalculous cholecystitis is a serious illness that has high morbidity and mortality. The reported mortality of the condition varies from 30 to 50% depending on the age of the patient. Even those who survive have a long recovery that can take months.

**Keywords:** cholecystitis, gallbladder, alithiasic

### **1. Introduction**

Acute alithiasic cholecystitis is defined as an inflammatory disease of the gallbladder in the absence of gallstones or obstruction of the cystic duct and it has a multifactorial pathogenesis [1].

It accounts for approximately 10% (range, 2% -15%) of all cases of acute cholecystitis. Acute alithisiac cholecystitis occurs in approximately 0.2% -0.4% of all critically ill patients. Duncan recognized it, for the first time, in 1844 when a fatal case of acute cholecystitis complicating an incarcerated hernia was reported [2]. Acute cholecystitis acalculous is associated with a morbidity more serious and a rate mortality more elevated compared to acute lithiasic cholecystitis [3].

The death rate depends primarily on the presentation already critical of the patient as the disease affects both medically and surgically compromised patients. Clinically, acute alithiasic cholecystitis is indistinguishable from acute lithiasic cholecystitis. Many patients with acute cholecystitis acalculous have the same symptoms of gallstone cholecystitis: pain in the quadrant abdominal upper right, fever, neutrophili leukocytosis, elevated liver enzymes (ALT, AST, Alkaline phosphatase) increased serum total bilirubinand fractional [4].

There are various risk factors that predispose to the formation of acute alithiasic cholecystitis which are listed in **Table 1**, as noted this pathology mainly


#### **Table 1.**

*Descending order of risk factors associated with acute alithiasic cholecystitis.*

affects patients in serious clinical conditions: severe trauma, patients with shock of any type on mechanical ventilation, with sepsis, burns or in total parenteral nutrition [6].

#### **2. Pathophysiology**

The etiology of acute cholecystitis acalculous is multifactorial, but is mainly formed by biliary stasis or organ wall ischemia. Biliary stasis can be caused by fasting, post-surgical total parenteral nutrition that leads to an increase in bile viscosity which irritates the mucous membrane of the gallbladder. Gallbladder wall ischemia occurs due to decreased blood flow due to fever, dehydration, or heart failure, which leads to the pathogenesis of acute cholecystitis [7].

It arises acutely when the walls of the gallbladder become inflamed for the reasons mentioned above [8].

Prolonged ischemia of the gallbladder walls leads to gangrene and then perforation. If the process occurs slowly, the formation of cholecystoduodenal (70%), cholecystocholic (10–20%), and the less common cholecystogastric fistula is possible. This will lead to sepsis and shock. These findings are referred to as acute cholecystitis. Chronic acalculous cholecystitis usually presents more insidiously. Symptoms are more prolonged and may be less severe. Symptoms may also be more intermittent and vague, although patients can present with signs of acute biliary colic [9].

#### **3. Epidemiology**

Acalculous cholecystitis has an incidence rate of 0.12% in the entire population. Rates are increased in HIV and other immunosuppressed patients. These individuals are more susceptible to certain opportunistic infections such as microsporidia, cytomegalovirus (CMV), and Cryptosporidium, which can seed and flourish in bile within the gallbladder [10].

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

Carriers of *G. lamblia*, *H. pylori*, and *S. typhi* are also associated with increased risks to develop cholecystitis.

It can occur in all breeds. Acute alithiasic cholecystitis has a slight male predominance (80% of case), unlike acute lithiasic cholecystitis, which has a female predominance and occurs at any age with a criticality threshold between the fourth and eighth decade of life [11].

## **4. Prognosis**

Acalculous cholecystitis is a serious illness that has high morbidity and mortality. The reported mortality of the condition varies from 30 to 50% depending on the age of the patient. Even those who survive have a long recovery that can take months [12].
