Acalculous Cholecystitis/Gangrenous Cholecystitis

[mfish714]

Hello all and thanks for any advice that you might give me. I'm a fourth year medical student on my sub-internship in the ICU. I've got a lady whom we have managed to bring back from the brink of death (ARDS/sepsis/on a rotaprone, etc.), but she's still hanging out in the ICU with a white count >20K and fevers spiking to the 103 range every day. The quick and dirty is that this lovely lady had a lap appy at OSH, developed sepsis 2/2 peritonitis, got better with abx. THEN she developed a pelvic abscess which was drained by IR, and again got better with abx. Thankfully she's been off pressors for about ten days now and is clinically much improved, but still remains septic. Now for the question. This is a lady whose CT scans show marked decrease in size of pelvic abscess with drain still in place and a little stable free fluid in the pelvis. She also has thickened GB wall with pericholecystic fluid. She ALSO has AST/ALT/Alk Phos about 4x normal (with normal hep panels) and a HIDA that shows filling of the GB, but EF of -181.4% (read as marked nonfunction of GB). She ALSO has induration and warmth over her RUQ with TTP. Now I know that scan rules out ACUTE cholecystitis, but what about acalculous or gangrenous? I'm sort of out of ideas. She's negative blood, urine, sputum, c. diff. Any thoughts?

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[ESU_MD]

ultrasound perc cholecystostomy tube- placed at the bedside.

I think its reasonable to take the gallbladder "out of the equation", although you can probably make similar arguments NOT to intervene on the gallbladder since it is filling on HIDA

usually a pretty low risk procedure. If there are no stones- then just cap the tube off once the pt gets better and pull it out in the office in a few weeks.

 

[Krazykritter]

Hello all and thanks for any advice that you might give me. I'm a fourth year medical student on my sub-internship in the ICU. I've got a lady whom we have managed to bring back from the brink of death (ARDS/sepsis/on a rotaprone, etc.), but she's still hanging out in the ICU with a white count >20K and fevers spiking to the 103 range every day. The quick and dirty is that this lovely lady had a lap appy at OSH, developed sepsis 2/2 peritonitis, got better with abx. THEN she developed a pelvic abscess which was drained by IR, and again got better with abx. Thankfully she's been off pressors for about ten days now and is clinically much improved, but still remains septic. Now for the question. This is a lady whose CT scans show marked decrease in size of pelvic abscess with drain still in place and a little stable free fluid in the pelvis. She also has thickened GB wall with pericholecystic fluid. She ALSO has AST/ALT/Alk Phos about 4x normal (with normal hep panels) and a HIDA that shows filling of the GB, but EF of -181.4% (read as marked nonfunction of GB). She ALSO has induration and warmth over her RUQ with TTP. Now I know that scan rules out ACUTE cholecystitis, but what about acalculous or gangrenous? I'm sort of out of ideas. She's negative blood, urine, sputum, c. diff. Any thoughts?

This actually wouldn't be all that uncommon. If I'm not mistaken (& someone I'm sure will correct me if I am) positive pressure ventilation is a not uncommon cause of acalculous cholecystitis. I would think w/ a CT scan w/ those results & a consistent clinical course, it should be fairly easy to argue that point.

Agree that perc cholecystostomy should be considered.

Article from accesssurgery.com or in Principles of Critical Care:
http://www.accesssurgery.com/Conten...cystitis+without+calculus&aid=2296123#2296130

 

[JackADeli]

...thickened GB wall with pericholecystic fluid. ...EF of ...(read as marked nonfunction of GB). She ALSO has induration and warmth over her RUQ with TTP. Now I know that scan rules out ACUTE cholecystitis...

I think what you are describing IS acute cholecystitis. Thickened GB wall, pericholecystic fluid, elevated WBC, TTP, etc... The scan does NOT rule out acute cholecystitis. The presence or absence of stones is irrelevant. It sounds advanced if she has abdominal wall induration & localized warmth to palpation. Beware possibility of secondary abdominal wall infection/necfasc/etc. If she is still gravely ill, start with percutaneous drainage and antibiotics. If she is stabilized out, consider operative resection. The nuances of operative vs perc drain can be numerous. So, in general generic scenario.... perc drain. Also, make sure you have eliminated other sources of infections as well... i.e. other indwelling foreign bodies.

...If I'm not mistaken (& someone I'm sure will correct me if I am) positive pressure ventilation is a not uncommon cause of acalculous cholecystitis...

Someone correct me if I am wrong. But, I am not sure positive pressure ventillation is the etiology of this disease process. I would think intermittent hypoperfusion (i.e. sepsis/vasoactive drip support) and/or NPO status with GB distention and/or biliary stasis are thought to be the etiologies. I have never heard a conclusive cause/effect relationship between PPV and acalc cholecystitis....

JAD

 

[Krazykritter]

I think what you are describing IS acute cholecystitis. Thickened GB wall, pericholecystic fluid, elevated WBC, TTP, etc... The scan does NOT rule out acute cholecystitis. The presence or absence of stones is irrelevant. It sounds advanced if she has abdominal wall induration & localized warmth to palpation. Beware possibility of secondary abdominal wall infection/necfasc/etc. If she is still gravely ill, start with percutaneous drainage and antibiotics. If she is stabilized out, consider operative resection. The nuances of operative vs perc drain can be numerous. So, in general generic scenario.... perc drain. Also, make sure you have eliminated other sources of infections as well... i.e. other indwelling foreign bodies.Someone correct me if I am wrong. But, I am not sure positive pressure ventillation is the etiology of this disease process. I would think intermittent hypoperfusion (i.e. sepsis/vasoactive drip support) and/or NPO status with GB distention and/or biliary stasis are thought to be the etiologies. I have never heard a conclusive cause/effect relationship between PPV and acalc cholecystitis....

JAD

I agree w/ you, JAD. There certaintly isn't a clear conclusive cause/effect relationship. I should have chosen my words more carefully, but in multiple critical care texts, intermittent positive pressure ventilation is a risk factor.

 

[JackADeli]

...in multiple critical care texts, intermittent positive pressure ventilation is a risk factor.

I hope my reply did not come accross as combative. I know what you are talking about.... I am going to reply mostly for medical students' and/or OP's benefit on this one.

I can also appreciate the idea of PPV causing backward venous stasis contributing to venous congestion to then ischemia.... I think, however, in general the PPV associated with significant venous compromise is also associated with a very sick patient with bigger fish in the frying pan.

Usually, the PPV is also in combination with ARDS/shock/sepsis/SIRS/etc... and their associated therapies for hemodynamic stabilization. I haven't heard of (though maybe that means little) of a pateint getting acute acalc cholecystitis from PPV doing 4 hour Nissen or a difficult inguinal hernia/lap appy/mastectomy/thyroidectomy/parathyroid/etc.... You often hear about it in major vascular patients that are sick or prolonged ICU sick patients..... If you read the earlier link to the critical care.... (yes they mention PPV), but mostly hypoperfusion/biliary stasis/etc....

Unfortunately, no complete explanation thus no complete prevention. I guess the unanswered question is a chicken and egg debate with relation to PPV and is it the cause of pathology or just an evil employed secondary to more global illness/pathology....So, I can't stand on some high mountain and proclaim full knowledge...

JAD

 

[dynx]

HIDA filling the gallbladder? not likely cholecystitis. Whats the bili. If it aint running into the small bowel you may have yourself a case of cholangitis. CBD stone could still have gallbladder filling.

 

[FliteSurgn]

If the gallbladder fills on HIDA, it is absolutely not acute cholecystitis....acalculous or otherwise. Period. Percutatneous cholecystosomy is not indicated. Period.

As for LFT abnormalities, I also doubt it is cholangitis. I would favor changes due to TPN or even due to a missed bowel injury if she has continuing signs of ongoing sepsis or reaccumulating fluid collections.