Gallbladder hydrops and acalculous cholecystitis

Gallbladder hydrops and acalculous cholecystitis are probably manifestations of the same disease entity but represent different points on a spectrum of symptoms and clinical signs. Acute distension of the gallbladder with wall oedema (hydrops) in the absence of any other biliary tract disease or an inflammatory component is rare but has been reported in association with sepsis and hypovol-aemic states including Kawasaki disease, severe diarrhoea with dehydration, hepatitis, scarlet fever and mesenteric adenitis. In this condition it is thought that bile stasis leads to functional obstruction of the cystic duct. The diagnosis is suspected in patients with a palpable, non-tender or mildly tender right upper quadrant mass that is subsequently confirmed to be the gallbladder with ultrasound. Secondary infection of a distended, hydropic gallbladder resulting from invasion of the gallbladder wall by organisms in the bile produces the clinical symptoms and signs of acalculous cholecystitis. In Western countries, acalculous cholecystitis may develop after shock, systemic sepsis, trauma, cardiac surgery, burns, Salmonella infection or in patients on parenteral nutrition. Many of these are patients receiving intensive care and initially the diagnosis may be occult. Clinical features include abdominal pain, vomiting, fever and localised right upper quadrant tenderness over the gallbladder which may be palpable. Patients typically have a raised white cell count and inflammatory markers. Ultrasound shows a markedly distended, thick-walled gallbladder, often containing echogenic debris. Patients are managed with intravenous fluid and antibiotics and bowel rest. Cholecystectomy or cholecystotomy are indicated in patients who fail to respond to conservative management and continue to deteriorate clinically.31,70

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