Gastroenterology,  Surgery

Acalculous Cholecystitis

The gallbladder in acalculous cholecystitis has stasis of bile within it and is also hypoperfused leading to inflammation (cholecystitis). 

By definition it is cholecystitis that occurs without a gallstone being present in the gallbladder. 

Acalculous cholecystitis is typically seen in patients that are critically ill. 

Risk factors include:

  • immunosuppression
  • recent surgery
  • total parenteral nutrition (TPN)
  • sepsis
  • hypotension

The diagnosis is made based on findings in the history and physical exam along with laboratory tests and imaging. 

Suspect acalculous cholecystitis in patients with risk factors (recent surgery, TPN, etc) who have right upper quadrant (RUQ) abdominal pain, fever, and positive Murphy’s sign. Look for elevated WBC. 

Helpful diagnostic tests include:

  • white blood cell count (WBC)
  • Liver enzymes (AST, ALT, ALP), congjugated bilirubin, amylase, lipase
  • Abdominal ultrasound


When cholecystitis is suspected, patients should be stratified based on whether they are high risk or low risk patients for surgery.

High risk patients: these patients are not best treated with surgery and instead a percutaneous cholecystostomy tube is placed.

Normal-low risk patients: these patients can undergo laparoscopic cholecystectomy, and then if the dissection was done well then can proceed to laparoscopic cholecystectomy. However, if the dissection 

Practice Cases

A 65 year old man presents with RUQ abdominal pain 3 days post-op. He has nausea, vomiting, and a mild fever. On exam, there is RUQ tenderness and a positive Murphy sign. Laboratory testing reveals elevated WBC. Abdominal ultrasound reveals a distended gallbladder with pericholecystic fluid but without any stones. 

Q: What is the most likley diagnosis?

Some useful reference resources for further reading include:

MDedge Family Medicine: Biliary pain, no gallstones—remove the gallbladder, anyway?

Thieme – Right Upper Quadrant Pain by William Middleton (sample chapter)

CGHjournal: Right Upper Quadrant Pain and a Normal Abdominal Ultrasound