Critical Care Medicine-Gastrointestinal, Nutrition and Genitourinary Disorders>>>>>Gallbladder and Biliary Tract
Question 2#

A 65-year-old male is now 10 days status post coronary artery bypass grafting with a postoperative course complicated by bleedingrequiring reoperation, and ventilator-associated pneumonia. After being afebrile for 2 days he spikes a temperature to 102°F and his laboratory test results demonstrate a new leukocytosis. An abdominal ultrasound is obtained that shows a distended gallbladder with wall thickening and pericholecystic fluid. A computed tomography scan of his abdomen confirms the aforementioned findings and is otherwise unremarkable.

From the following choose the correct diagnosis and treatment. 

A. Acalculous cholecystitis—laparoscopic cholecystectomy
B. Acalculous cholecystitis—percutaneous cholecystostomy tube
C. Acalculous cholecystitis—endoscopic retrograde cholangiopancreatography
D. Acute calculous cholecystitis—laparoscopic cholecystectomy
E. Acute calculous cholecystitis—percutaneous cholecystostomy tube

Correct Answer is B


Correct Answer: B

Acalculous cholecystitis is an inflammatory disease of the gallbladder, which occurs in the absence of gallstones and is multifactorial in etiology. Acalculous cholecystitis accounts for approximately 10% of cases of acute cholecystitis and is typically seen in critically ill patients, such as the one described above. Risk factors for acalculous cholecystitis include, but are not limited to, major trauma, burns, sepsis, prolonged total parenteral nutrition, and congestive heart failure. Diagnosis involves high clinical suspicion of the clinician in the appropriate clinical setting and can be confirmed with standard laboratory evaluation and imaging studies including either ultrasonography or computed tomography. In cases where the diagnosis is still uncertain, cholescintigraphy (HIDA scan) can be used. Delay in treatment can result in bacterial superinfection and potential gallbladder perforation. In addition to initiation of antibiotic therapy, definitive therapy with either cholecystectomy or gallbladder drainage is warranted. Of the above choices, Answer B provides the correct diagnosis (acalculous cholecystitis) and the most appropriate method of gallbladder drainage (percutaneous cholecystostomy tube) in the setting of recent cardiac surgery and critical illness. Endoscopic retrograde cholangiopancreatography does not provide appropriate gallbladder decompression as mechanical obstruction is not the cause in acalculous cholecystitis. 


  1. Afdhal NH. Acalculous Cholecystitis: Clinical Manifestations, Diagnosis, and Management. UpToDate. Updated July 18, 2018.
  2. Barie PS, Fischer E. Acute acalculous cholecystitis. J Am Coll Surg. 1995;180(2):232.