Acalculous cholecystitis: the use of diagnostic laparoscopy

Acalculous cholecystitis (AC) carries a high mortality in the critically ill patient. This is partly due to the delay in its diagnosis. Clinical diagnostic examinations are often misleading. The purpose of our study was to evaluate the use of laparoscopy as a diagnostic tool in the evaluation of the critically ill patient suspected of having AC. From May 1993 to January 1994, we evaluated 10 critically ill patients. Mean age was 56 years (range 17-90 years). Nine of the patients were trauma victims (8 blunt, 1 penetrating). The other patient was postcoronary bypass surgery. The laparoscopy was done after a mean of 15 days (range 6-54 days) after ICU admission. All patients were receiving ventilatory support, and all patients had elevated temperatures of greater than 38.5 degrees C. Five patients had abdominal tenderness, and 6 had elevated liver function tests (LFT). Six laparoscopies were done under local anesthesia and IV sedation at the bedside, and 4 were done in the operating room. All patients tolerated the procedure well with no complications. The laparoscopic findings were gangrenous cholecystitis in 2 patients. They both underwent laparoscopic cholecystectomies in the operating room. We elected to drain a very distended gallbladder in 1 patient, who eventually was found to have an empyema of the chest. The other 7 examinations were normal. Six of these patients recovered and were discharged. Our results suggest that laparoscopy can be used in the diagnosis of acalculous cholecystitis. Its positive and negative findings are valuable in the treatment of the critically ill. It can be done safely at the bedside.