Acute acalculous cholecystitis in intensive care.

Acute acalculous cholecystitis is increasingly being recognised as a complication of critical illness. The disease usually develops on a background of prolonged illness following multiple trauma, extensive burns, severe sepsis, major surgery or drug overdosage. The clinical picture is virtually indistinguishable from acute obstructive cholecystitis and the diagnosis is often made at laparotomy.' We report three cases which occurred over a nine-year period in a six bedded intensive care unit. CASE 1. A 39-year-old male with longstanding ankylosing spondylitis underwent manipulative spinal osteotomy to correct spinal deformity. Four days later he became profoundly shocked, with respiratory and renal failure. Initial laparotomy revealed a large perforated gastric ulcer. A long complicated illness ensued, with prolonged respiratory failure necessitating artificial ventilation via a tracheostomy, inotropic support, and haemodialysis. Another laparotomy was performed on the seventeenth day to drain a subphrenic abscess; a distended gangrenous gallbladder was found and removed. Four months after the start of his illness, a third laparotomy was done because of persistent vomiting. There were widespread adhesions and infected bile escaped during mobilisation of the right colonic flexure, which was adherent to the remains of the gallbladder bed. Candida atbicans was cultured from a specimen of bile, and the same organism was isolated from blood cultures. This man was nearly six months in intensive care, and we were later able to identify a deficiency of the trace element selenium.2 CASE 2. A 22-year-old female developed acute renal failure secondary to postoperative hypovolaemia and hypotension following small-bowel resection for adhesions and gangrenous bowel. She was transferred to this hospital for dialysis. A second laparotomy, one week after the first, revealed further necrotic bowel which was resected. There were about two litres of green fluid in the abdominal cavity and the gallbladder was noted to be stained a deep green colour but otherwise seemed healthy. She remained acutely ill after this operation with paralytic ileus, large naso-gastric aspirates, tachycardia and hypertension. She