Acalculous Cholecystopathy - Causes, Symptoms, Complications, Treatment.

Introduction

Acalculous cholecystopathy is a dysfunction or hypokinesis of gallbladder emptying. However, the more commonly encountered reason behind cholecystitis is mechanical blockage of the gallbladder outlet at the cystic by gallstones. The condition of acalculous cholecystitis was first described by Duncan in 1844.

Acalculous cholecystitis is a more life-threatening disorder than calculous cholecystitis due to the chances of perforation and necrosis. Acalculous cholecystopathy is frequently reported in elderly patients. The common signs are pain in the upper right quadrant of the abdomen and the presence of Murphy's sign. The treatment of choice is cholecystectomy. Temporary decompression of the gallbladder can be done by percutaneous drainage of the gallbladder or stent placement through endoscopic retrograde cholangiopancreatography (ERCP).

What Are the Causes of Acalculous Cholecystopathy?

Often the exact etiology behind acalculous cholecystopathy is unknown, but a few conditions and disorders can lead to the disease.

1. Gallbladder dysfunction can be caused due to long-duration fastings, drastic weight loss, or complete parenteral nutrition.

2. Patients in the ICU (intensive care unit), due to serious conditions such as stroke, heart attack, severe burns, sepsis, or extensive trauma, are at higher risk of developing acalculous cholecystography.

3. Due to a lack of gallbladder stimulation, there can be a concentration of bile salts, which builds up pressure within the organ. This can lead to pressure necrosis, ischemia (restriction of blood flow to a body part), and eventually perforation. The accumulation of bile salts can lead to increased growth of enteric pathogens such as Klebsiella, Escherichia coli, Pseudomonas, and Enterococcus faecalis.

4. Acalculous cholecystopathy can follow abdominal trauma in some cases.

5. Patients suffering from the following diseases can also have acalculous cholecystography:

• Systemic Vasculitis: Inflammation of the arteries or veins, which can progress to necrosis and lead to narrowing of the vessels.

• Systemic Lupus Erythematosus: It is a condition in which the immune system of the body attacks its tissue, leading to widespread inflammation and tissue death in the affected organ. It affects organs such as skin, joints, lungs, kidneys, brain, and blood vessels.

• Henoch-Schonlein Purpura: It is also known as immunoglobulin A (IgA) vasculitis. This condition may cause inflammation and bleeding of small blood vessels.

• Kawasaki Disease: An acute illness that causes inflammation in the walls of a few blood vessels is called Kawasaki disease. It is common in children less than five years of age.

What Is the Pathophysiology of Acalculous Cholecystopathy?

In acalculous cholecystography, there is a stasis in the gallbladder, leading to a build-up of intraluminal pressure. This causes ischemia of the gallbladder wall and inflammation. The stasis may be responsible for the colonization of the bacteria, which causes an inflammatory response. If the pressure is not relieved, it may lead to gangrenous changes and perforation of the gallbladder wall. These changes may further lead to shock and sepsis. These findings suggest acute cholecystitis. Symptoms of chronic acalculous cholecystitis are more prolonged and less severe. Symptoms may appear intermittently and are found to be vague. It was found that affected individuals may present with signs of acute biliary colic.

What Is the Toxicokinetics of Acalculous Cholecystopathy?

Mild cases of acalculous cholecystitis are managed for symptoms of biliary colic. Cases of acute cholecystitis may result in sepsis and shock. The pressurized bile in the gallbladder may be susceptible to bacterial seeding. The antibiotics are found to be ineffective because of the increased intraluminal pressure and compromised intraluminal blood supply. The eventual perforation may result in bile peritonitis, which gives rise to shock and sepsis.

What Are the Symptoms of Acalculous Cholecystopathy?

• Abdominal pain: The most common symptom noticed is abdominal pain in the right upper quadrant.

• Fever: Pain and fever are the most common symptoms of acalculous cholecystopathy.

• Presence of Murphy’s Sign: It is a sign tested in cases of acute cholecystitis. The patient is asked to inspire and hold a deep breath; meanwhile, palpation is done in the right subcostal area. The pain occurs when an inflamed gallbladder comes in contact with the examiner's hand.

• Nausea: The feeling of uneasiness and vomiting.

• Food intolerance: Food intolerance and vomiting can be observed.

• Bloating: Fullness or tightness of the abdomen.

• Belching: It is commonly known as burping and means the expulsion of extra air from the upper digestive tract

• White blood cell count: There can be a rise in white blood cell count.

• Jaundice: Pallor or yellowish discoloration of the skin, sclera of the eye, and mucous membrane is termed jaundice. However, it is a less likely symptom of this condition.

What Are the Complications in the Gallbladder in Severe Cases?

The gallbladder walls may exhibit swelling, and there may be a lack of oxygen supply (ischemia) leading to gangrene formation. If the gangrene remains for a long time without treatment, an infection may develop from gas-forming organisms causing acute emphysematous cholecystitis. The infection can further cause perforation leading to a life-threatening condition.

How to Diagnose Acalculous Cholecystopathy?

• The test of choice for acalculous cholecystopathy is a cholescintigraphy nuclear scan (HIDA) with the administration of cholecystokinin. The cholecystokinin stimulates the emptying of the gallbladder. A calculated ejection fraction of 35 percent or less indicates hypokinetic (slow) functioning of the gallbladder.

• Ultrasound: It helps to evaluate the thickening of the gallbladder wall. If the thickness is less than 3.5 mm, the cause is cholecystography.

What Is the Treatment of Acalculous Cholecystopathy?

• In the majority of cases, patients with acalculous cholecystectomy are ill for a very long time and need to be stabilized before performing any treatment procedure.

• The treatment of choice for chronic acalculous cholecystopathy is cholecystectomy. It can be laparoscopic or open cholecystectomy.

Laparoscopic Cholecystectomy: It is the minimum invasive cholecystectomy involving the removal of the gallbladder. This procedure is performed through four small incisions, a camera that helps to visualize inside the abdomen and a few long tools that help remove the gallbladder. The surgery was performed after anesthesia administration. The patient can come back home either on the same day or the next day of surgery.

• If the patient is not stable for major surgery, then percutaneous drainage can be performed temporarily. A tube is placed in the gallbladder to decompress it. Once the patient is stable, cholecystectomy is done.

• Broad-spectrum antibiotics are routinely administered to treat systemic bacteremia.

What Is the Prognosis of Acalculous Cholecystopathy?

The condition called acalculous cholecystitis is considered serious and has increased morbidity and mortality. It was noticed that 30 to 50 percent of mortality may be seen, and this is based on the age of the affected persons. The recovery was found to be lengthy and may take months.

Which Diseases Are Similar to Acalculous Cholecystopathy?

• Cholangitis: Inflammation of the bile duct that occurs because of any bacterial infection. The bile duct carries bile from the liver to the gallbladder and the intestine.

• Mesenteric Ischemia: Inadequate blood in a portion of the intestine is because of the blockage in an artery. The sudden loss of blood flow may result in the formation of a clot, which should be treated immediately by surgery.

• Appendicitis: Appendicitis is the inflammation of the appendix that leads to severe abdominal pain on the right side of the abdomen.

• Peptic Ulcer Disease: It is an inflammatory lesion present on the lining of the stomach and intestines with bleeding and infection.

• Pancreatitis: Pancreatitis is the inflammation of the pancreas and can also show symptoms similar to acalculous cholecystopathy.

• Acalculous Biliary Colic: Biliary colic without gallstones is known as acalculous biliary colic and is caused by structural or functional issues. Laparoscopic cholecystectomy or endoscopic sphincterotomy may be used to treat this condition.

Conclusion:

Dysfunction of the gallbladder emptying in the absence of any gallstone is known as acalculous cholecystopathy. It is a life-threatening condition as it occurs in critically ill patients already infected by any serious disease. The symptoms include abdominal pain on the right side with the presence of Murphy's sign. Treatment is necessary in cases of acalculous cholecystopathy as it can lead to ischemia and gangrene formation further.