Acute acalculous cholecystitis may develop in critically ill patients in the intensive care unit (ICU). The diagnosis can often be made based on sonographic findings.


Sonographic features:

(1) increased wall thickness (a) > 3.5 mm (b) > 4.0 mm

(2) hydrops (length > 8 cm and transverse diameter > 4 cm)

(3) sludge within the gallbladder (nonmobile echogenic foci with diffuse acoustic shadowing)

(4) double layer (subserosal edema, with echolucent mural band)

(5) fragmentation or sloughing of the gallbladder wall

(6) pericholecystic fluid collection (pericholecystic echolucency)

(7) emphysematous change (intramural or intraluminal echogenic foci with reverberations)

(8) hemorrhage (intramural echo cluster without acoustic shadow)

(9) response to cholecystokinin (a) complete (b) partial

(10) pericholecystic fat infiltration

(11) positive sonographic Murphy’s sign (localization of pain to the gallbladder)


The performance of sonography in the diagnosis of acalculous cholecystitis depends on which of the criteria are used for diagnosis.


Waydhas et al, Imhof et al and Raunest et al used items 1a, 2 and 3 as major criteria (the “triad”) and items 4,5 and 6 as minor criteria.


Kalliafas used items 1b, 4, 5, 6, 7, 9a, 10 and 11 as major criteria and items 2, 3 and 9b as minor criteria.


Puc et al used items 1a, 6 and 7 as major criteria and items 2 and 3 (along with cholelithiasis) as minor criteria.


A sonographic study may be suboptimal if the patient has had intra-abdominal surgery with sutures and wound packing.


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