Acute acalculous cholecystitis--a clinical-pathological disease spectrum.

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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.

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