ICU · Gastroenterology
Acute cholecystitis in ICU: severe and complicated presentations
Also known as Acute cholecystitis · Gallbladder empyema · Gangrenous cholecystitis · Emphysematous cholecystitis · Acalculous cholecystitis
Acute cholecystitis: inflammation of gallbladder, usually from cystic duct obstruction by gallstone (90-95%). ICU-relevant severe presentations: (1) GANGRENOUS cholecystitis (wall necrosis → perforation, mortality 15-30%). (2) EMPHYSEMATOUS cholecystitis (gas-forming organisms in wall — Clostridium, E. coli — mortality 15-25%). (3) ACALCULOUS cholecystitis (10% — critically ill patients, no stones — ischaemia, biliary stasis; mortality 30-50%). (4) PERFORATION (localised abscess or free perforation with bilious peritonitis). (5) EMPYEMA (pus-filled gallbladder — surgical emergency). Severe presentations need ICU for sepsis, organ failure, post-operative care. Management: antibiotics (gram-negative + anaerobic cover), cholecystectomy (early laparoscopic for fit; percutaneous cholecystostomy for unfit/critically ill).
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Target exams
Red flags
- Emphysematous cholecystitis (gas in gallbladder wall) — gas-forming organisms, mortality 15-25%, diabetic patients over-represented
- Acalculous cholecystitis in critically ill ICU patient — mortality 30-50%, often diagnosed late
- Gallbladder perforation — free perforation causes bilious peritonitis (mortality 30%), localised forms abscess
- Gallbladder empyema — surgical emergency, risk of sepsis and perforation
- Ascending cholangitis may coexist — check for Charcot's triad / Reynolds' pentad
Meet the patient
A 68-year-old man with type 2 diabetes and obesity arrives after four days of right upper quadrant pain, fever, and rigors. He is confused, hypotensive on noradrenaline, lactate 4.8, and the CT shows gas layered in the gallbladder wall. This is emphysematous cholecystitis with organ dysfunction — Tokyo Guidelines Grade III — and the question that decides his next six hours is whether he can survive an operating table tonight.[6]
Hold that image and the whole topic lines up behind it. The critically ill gallbladder fails by a predictable cascade — obstruction, distension, ischaemia, infection — and the ICU-relevant variants are simply the points along that cascade where the wall dies, fills with gas, or bursts.[7]
References23ShowHide
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- [18]Gomi H, Solomkin JS, Schlossberg D, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis J Hepatobiliary Pancreat Sci, 2018.PMID 29090866
- [19]Pisano M, Allievi N, Gurusamy K, et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis World J Emerg Surg, 2020.PMID 33153472
- [20]Jagtap N, Kulkarni AV, Venkat Rao G, et al. Urgent versus early ERCP in mild-to-moderate acute cholangitis: a randomised controlled trial Gut, 2026.PMID 42161575
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- [24]Hung BT, Traylor KS, Wong CY Revisiting morphine-augmented hepatobiliary imaging for diagnosing acute cholecystitis: the potential pitfall of high false positive rate Abdom Imaging, 2014.PMID 24402474