A 75-year-old hospitalized man is evaluated for abdominal pain and fever. The patient was admitted 2 weeks ago due to necrotizing fasciitis of the gluteal region and severe sepsis. He has been treated with surgical debridements, intravenous antibiotics, and fluids. For the past 2 days, the patient has had right upper quadrant abdominal pain, nausea, and recurrent fever. He has a history of hypertension, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. His temperature is 38.8 C (102 F). Physical examination shows marked tenderness over the right subcostal area. Leukocyte count is 18,000/mm³ compared to 9,600/mm³ 2 days ago. Laparoscopic surgery is planned. Which of the following will most likely be found during this patient's surgery?

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This patient likely has acute acalculous cholecystitis, an acute inflammation of the gallbladder in the absence of gallstones. Acalculous cholecystitis most commonly occurs in critically ill patients (eg, those with sepsis, severe burns, trauma, immunosuppression) and is associated with high mortality. The condition is thought to arise secondary to gallbladder stasis and ischemia, which cause inflammation of and injury to the gallbladder wall. Clinical manifestations may be subtle, especially in those who are sedated or intubated. Fever, right upper quadrant pain, a positive Murphy's sign, leukocytosis, and mild elevations in liver function tests are often present. Physical examination may demonstrate jaundice and a palpable right upper quadrant mass. The diagnostic study of choice is an ultrasound, which may show signs of acute cholecystitis (eg, an edematous and enlarged gallbladder) and no gallstones. (Choice A) Choledochal cysts are congenital dilations of the common bile duct that typically present during childhood (age <10) with recurrent abdominal pain and jaundice. (Choice B) Chronic cholecystitis results from repeated mild attacks of acute cholecystitis, which leads to thickening of the gallbladder wall. Ultrasound typically demonstrates a shrunken, fibrosed gallbladder. (Choice C) Liver fluke infection usually affects individuals from endemic areas (eg, Southeast Asia) and presents acutely with fever, right upper quadrant pain, jaundice, and eosinophilia. Infection of the biliary tree is associated with the formation of brown pigment gallstones, not acute acalculous cholecystitis. (Choice E) Pigment gallstones are categorized as black (typically secondary to intravascular hemolysis) or brown (typically secondary to biliary infection). These gallstones are associated with acute calculous cholecystitis, not acute acalculous cholecystitis. (Choice F) Porcelain gallbladder is usually found incidentally on abdominal radiograph as a rim of calcium deposits outlining the gallbladder. The condition is associated with chronic cholecystitis and may increase the risk of gallbladder carcinoma. Educational objective: Acute acalculous cholecystitis is an acute inflammation of the gallbladder in the absence of gallstones. It typically occurs in critically ill patients (eg, those with sepsis, severe burns, trauma, immunosuppression) due to gallbladder stasis and ischemia. Clinical findings may be subtle and include fever, right upper quadrant pain, and leukocytosis. __________ References: Acute acalculous cholecystitis: a review. (http://www.ncbi.nlm.nih.gov/pubmed/19747982)

A 75-Year-Old Hospitalized Man Is Evaluated for Abdominal Pain and Fever