The incidence of acute acalculous cholecystitis in critically ill COVID-19 patients

Abstract

Coronavirus disease 2019 (COVID-19) can cause severe acute respiratory failure requiring admission to the intensive care unit (ICU). Over time, it has become clear that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) not only affects the respiratory system, but also has an impact, directly or indirectly, on many organs in the body, including the liver. Here we present three patients diagnosed with severe COVID-19 who developed acute acalculous cholecystitis (AAC) after a prolonged ICU stay.AAC is a rare form of cholecystitis not associated with the presence of gallstones. In this case, inflammation of the gallbladder is due to hypomotility, which induces accumulation of bile with a secondary increase in intraluminal pressure that leads to inflammation, ischemia, and necrosis of the gallbladder wall [1,2]. The accumulation of bile can also promote bacterial colonization and sepsis. Numerous factors can contribute to the hypomotility that is the main stimulus that drives contraction and emptying of the gallbladder, including hemodynamic instability, dehydration, positive end-expiratory pressure in mechanically ventilated patients (by reducing hepatosplanchnic blood flow), opioid analgesics, sedation, and prolonged periods without enteral nutrition.Between March 2020 and March 2021, 126 patients with COVID-19 were admitted to our ICU; of these, 96 required invasive mechanical ventilation (IMV). Three patients developed AAC. All these critically ill patients were included in a Spanish registry of COVID-19 patients, which was approved and exempted from the requirement for patient informed consent by Ethics Committee of our Hospital (123/2020).The first case, a 73-year-old man, was admitted to the ICU for acute respiratory distress syndrome (ARDS) secondary to COVID-19. The patient required IMV for 34 days and enteral nutrition during the entire ICU stay. After 41 days in the ICU, the patient was discharged to the inpatient ward. Two days later, he developed abdominal pain and fever along with elevated C-reactive protein (CRP) levels. Abdominal ultrasound showed a hydropic gallbladder with thickened walls and incipient necrosis (Figure 1). Due to the patient's frail condition, percutaneous drainage was performed, and antibiotics were administered. The patient responded well, and there was no need for cholecystectomy.The second patient, a 42-year-old man, was similarly admitted to the ICU for ARDS secondary to COVID-19. The patient required IMV for 35 days and received enteral nutrition

Aetiology, diagnosis and management for ischaemic cholecystitis: current perspectives

“…18 More recently, Franch-Llasat et al reported 3 cases of 'acalculous cholecystitis' diagnosed in patients who were admitted to the ICU for acute respiratory distress syndrome secondary to COVID-19 infection. 21 Of note, all three patients were diagnosed with 'acalculous cholecystitis' after being discharged from the ICU (2, 12 and 20 days after discharge), highlighting that there may be a delay in the manifestation of ischaemic cholecystitis after a critical illness.…”

Acalculous Cholecystitis in COVID-19 Patients: A Narrative Review

“…Several reports in the literature have described the presentation of acute cholecystitis in COVID-19 patients, with most of them being case reports and letters to the editor and some case series ( Table 1 ) [ 10 , 19 , 20 , 21 , 22 , 91 , 92 , 94 , 95 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 , 114 ].…”

“…Several reports in the literature have described the presentation of acute cholecystitis in COVID-19 patients, with most of them being case reports and letters to the editor and some case series (Table 1) [10,[19][20][21][22]91,92,94,95,[100][101][102][103][104][105][106][107][108][109][110][111][112][113][114]. Bruni et al, described the first case of histopathological findings of an acute ischemic gangrenous cholecystitis as a late complication in a COVID-19 [95].…”