■ parenteral nutrition,

■ prolonged fasting.

As can be seen from the list above, the risk factors are often fulfilled by patients on intensive care units. Clinical presentation may be non-specific with fever, pain (either right upper quadrant or generalised abdominal pain), leukocytosis and elevated liver enzymes or bilirubin. A small proportion of patients with acalculous cholecystitis are made up of outpatients and children. Diagnosis is more straightforward in this group. On the intensive care unit, it is a difficult diagnosis to make both clinically and radiologically. Delay in diagnosis and the related/predisposing conditions mean that it is associated with a high degree of morbidity and complications. Complications include gall bladder perforation, gangrene and emphysematous cholecystitis.

Ultrasound features include gall bladder wall thickening, gall bladder wall oedema, pericholecystic fluid, intramural gas, gall bladder distention and an ultrasonographic murphys sign. Several of the ultrasound features are non-specific - such as gall bladder wall thickening which can be seen with other conditions, e.g. hypoalbuminemic states and heart failure. Early follow-up looking for interval change can be helpful if the diagnosis is in doubt. CT is an alternative imaging modality, but is clearly less portable.

Treatment options

■ Open cholecystectomy.

■ Laparoscopic cholecystectomy.

■ Percutaneous cholecystostomy (see Fig. 7.20).

■ Percutaneous aspiration.

Fig. 7.20 Acalculous cholecystitis. Percutaneous cholecystostomy. Using local anaesthesia at the bedside, with ultrasound guidance a drainage catheter can be placed into the gall bladder. A locking pigtail drain can be placed as either a one-step trocar insertion or with serial dilation over a wire. A transhepatic route may reduce the risk of inadvertant drain movement. Note the echoes from the needle.

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