The importance of early diagnosis of acute acalculus cholecystitis

Most observations of acute acalculus cholecystitis have been reported in patients after trauma, after unrelated surgical treatment and in critically ill patients, patient populations in whom the diagnosis of this condition is difficult. The importance of making an early diagnosis is demonstrated by the rapid development of complicated forms of cholecystitis. The results of collective reports have indicated that 40 to 100 per cent of the patients with acute acalculus cholecystitis will have advanced disease with gangrene, empyema or perforation of the gallbladder at operation. To demonstrate the importance of early suspicion and the use of sonography in making the diagnosis of this condition, a retrospective study of 40 patients with a surgical and pathologic proved diagnosis of acute acalculus cholecystitis was conducted. The fulminant nature of this disease was underscored by the fact that 70 per cent of these patients had advanced disease. Patients were divided into two groups, those who underwent operation within 48 hours of the onset of symptoms and those whose surgical treatment was delayed. Forty per cent of the patients who underwent operation more than 48 hours after the onset of symptoms had gallbladder perforation, while only 8 per cent of the patients without a delay in surgical treatment of more than 48 hours had perforations. Since advanced disease, especially perforation, carries a much higher morbidity and mortality than uncomplicated cholecystitis, making an early diagnosis is of paramount importance. Therefore, heightened awareness on the part of physicians is a key in making an early diagnosis. In 25 per cent of the patients in this study, unexplained fever was the first sign of the disease. Although most patients later presented with more classic symptoms of cholecystitis, many of these patients still presented with confusing clinical signs and symptoms leading to a delay in diagnosis due to the coexistence of the post-trauma, postsurgical or critically ill state. Ultrasound proved to be an important adjunct to the often confusing clinical clues in making an early diagnosis. Three ultrasonographic signs in the absence of stones--1, a thickened gallbladder wall; 2, an enlarged tender gallbladder, and 3, a pericholecystic collection--were suggestive of acute acalculus cholecystitis. One of these findings was present in almost 90 per cent of the patients in this study with acute acalculus cholecystitis who underwent biliary ultrasound.