Episode 101: Acalculous cholecystitis with Dennis Kim

This episode of Critical Care Scenarios dives deep into the diagnosis and management of acalculus cholecystitis in critically ill ICU patients, using a detailed case presentation of a 72-year-old male with sepsis from pneumonia who develops persistent instability despite treatment. The discussion, led by hosts Brian Bolling and Brandon Odo with guest Dr. Dennis Kim, explores the clinical challenges of distinguishing acalculus cholecystitis from other causes of ongoing sepsis, such as mesenteric ischemia or pancreatitis. Key diagnostic tools like ultrasound, CT, and HIDA scans are evaluated, with emphasis on the limitations of non-contrast CT and the importance of clinical context. The episode highlights that while acalculus cholecystitis is less common today due to early enteral feeding, it remains a critical consideration in patients with unexplained fever, abnormal LFTs, and persistent hemodynamic instability. Management hinges on a tiered approach: percutaneous cholecystostomy as first-line for uncomplicated cases, with surgical intervention reserved for complicated, gangrenous, or perforated disease. The episode also addresses practical workflow issues, including when to consult surgery, the role of GI in endoscopic cystic duct stenting (rarely used), and the importance of follow-up tube cholecystography before drain removal. A recurring theme is the need to recalibrate diagnostic suspicion in the ICU, where non-specific findings are common, and to prioritize interventions that align with patient-specific risk and institutional resources. Key takeaways include: 1) Acalculus cholecystitis should be considered in any critically ill patient with persistent sepsis and abnormal LFTs, especially those who are NPO or on mechanical ventilation. 2) Early enteral feeding is likely protective and may reduce incidence. 3) A percutaneous cholecystostomy is the preferred initial intervention for uncomplicated cases, not surgery. 4) HIDA scans are the gold standard but are often impractical in ICU settings; their use should be guided by pretest probability. 5) Drain removal requires a tube cholecystogram to confirm cystic duct patency. 6) Surgeons are valuable for complex cases and outpatient follow-up, even if not needed for initial management. 7) Avoiding non-contrast CT is critical—contrast should be used to ensure diagnostic accuracy. 8) Always assess for right upper quadrant tenderness and perform bedside exams, even in intubated patients.