Acalculous cholecystitis in the critically ill: evolving insights into diagnosis and management

This review examines recent literature on the pathogenesis, diagnosis, and management of acalculous cholecystitis (AAC), emphasizing evolving imaging, interventional techniques, and risk stratification. Although patients may present a clinical picture of inflammation of the gallbladder without radiographic evidence of calculi within the gallbladder, there is a select group of critically ill patients with unexplained sepsis that require special attention. A major distinction in etiology starts with possible obstructive vs. nonobstructive cholecystitis. Nonobstructive causes of cholecystitis, both from biliary stasis and ischemia, are important for the diagnosis and management of AAC.

Recent studies indicate a rising incidence of AAC, likely reflecting an aging population and longer ICU stays in critically ill patients. Diagnostic tools such as ultrasonography and computed tomography remain first-line, whereas hepatobiliary scintigraphy is reserved for indeterminate cases. Emerging trends focus on prevention, improving timely diagnosis, refining risk stratification, and expanding minimally invasive drainage options - including percutaneous and endoscopic approaches - for patients unfit for surgery. Early broad-spectrum antibiotics and preventive strategies are critical to improving outcomes.

AAC is a complex and heterogeneous disease with evolving diagnostic and therapeutic paradigms. Preventive strategies are likely to emerge as specific etiology becomes more apparent. Future research should refine predictive algorithms, clarify etiologic distinctions, and optimize interventional management to reduce morbidity in high-risk populations.