Acute acalculous cholecystitis - A clinical pathological disease spectrum
Objective. To assess the influence of disease setting on clinical and pathological features of acute acalculous cholecystitis (AAC). Design. Analysis of prospectively accumulated clinical data. Blinded histopathological review. Location of study. Tygerberg Hospital, Western Cape. Patients. Fifty-seven consecutive patients with AAC treated over a 9-year period. Main outcome measures. Clinical, ancillary and pathological features of AAC in each of 3 arbitrarily designated types. Type I (N = 24) occurred in patients hospitalised for trauma or critical illness. Patients with type II disease (N = 20) presented primarily with symptoms of acute cholecystitis. Type III AAC (N = 13) was associated with non-calculous gallbladder outflow obstruction. Results. Type I AAC was associated with the highest mortality rate (45.8%), occurred predominantly in males (75%) and was diagnosed pre-operatively in 50% of patients. Acute ischaemic cholecystitis was the most frequent histological diagnosis (66.7%). Only 1 death (5%) was associated with type II AAC despite patients being older, and all but 2 patients (10%) having chronic underlying disease. Acute cholecystitis was diagnosed pre-operatively in 90% of patients. Thirteen patients (65%) were males. Acute-on-chronic cholecystitis was the most frequent histological diagnosis (50%), followed by acute ischaemic cholecystitis in 30%. Type III was associated with an intermediate mortality rate (23.1%) and was the type most seldom diagnosed pre-operatively (15.4%). Histological findings reflected the nature and duration of underlying obstructive pathology. Conclusion. The circumstances in which AAC occurs appear to be associated with distinct clinical-pathological variants of the disease. Their recognition could serve to enhance understanding of this challenging condition.