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      Acute acalculous cholecystitis as a rare manifestation of chronic mesenteric ischemia. A case report

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          • Acute acalculous cholecystitis can present de novo in an outpatient setting without any major illness or associated trauma and aortic occlusive disease may represent the most relevant etiological factor in these patients.

          • In the settings of chronic mesenteric ischemia, acute acalculous cholecystitis may be interpreted as a herald sign of critical ischemia and mesenteric infarction as a consequence of an acute-on-chronic mesenteric ischemia.

          • In our patient, the decision was taken to proceed with immediate mesenteric revascularization simultaneously with the cholecystectomy in order to minimize the risk and extension of a possible bowel infarct.



          Symptomatic chronic mesenteric ischemia (CMI) is an uncommon condition that usually presents with intestinal angina, sitophobia and unintentional weight loss. Acute acalculous cholecystitis (AAC) has very rarely been described in the settings of CMI.

          Presentation of case

          We describe a case of a 73 year old man that developed an AAC as a complication of CMI. The patient underwent a simultaneous cholecystectomy and open aortic revascularization which was successful. At 24 months of follow-up the patient is clinically well and regained weight.


          Ischemia has been considered an important etiology for the development of AAC. In the settings of CMI, an AAC might develop has a herald sign of progression to acute mesenteric ischemia and infarction, as the cystic artery is a terminal artery with no collateral network. Performing the aortic revascularization simultaneously with the cholecystectomy might prevent this possible fatal outcome.


          This case reinforces aortic and visceral occlusive disease as a possible risk factor for the development of AAC, and discusses the treatment controversies when managing both conditions simultaneously.

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          Most cited references 20

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          Clinical features of acute acalculous cholecystitis.

           K Ryu,  J Ryu,  In Je Kim (2003)
          Acute acalculous cholecystitis (AAC) tends to have a fulminant course and be associated with critically ill diseases, there have been reports of AAC without any risk factors but good prognosis. To assess the risk factors, clinical features and prognosis of AAC. All patients who had a cholecystectomy due to acute cholecystitis at Pundang Jesaeng General Hospital during a 43-month period were prospectively enrolled. AAC was defined by ultrasonographic, intraoperative and pathologic findings of acute cholecystitis without evidence of gallstones. Clinical features and pathologic findings were analyzed and outcome was assessed. 156 patients with acute cholecystitis were enrolled and 14% (22 of 156) met the criteria of AAC. Fifteen (68%) of the patients with AAC were male and the average age was 63 year old. Twenty patients were presented with AAC as outpatients of whom seven of them (35%) had atherosclerotic vascular disease. Laparoscopic cholecystectomy was performed in 126 patients (80.8%) with acute cholecystitis but was possible in only 12 patients (54.5%) with AAC. AAC was associated with a high incidence of gangrene (59%) but no patients died of acute cholecystitis. We conclude that AAC frequently occurs in elderly male outpatients without critical illness and gangrene is common but the prognosis is better than reported previously.
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            Microangiopathy in acute acalculous cholecystitis.

            Acute acalculous cholecystitis is a well recognized complication of many acute illnesses. Ischaemia of the gallbladder seems to have an important role in its pathogenesis.
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              Chronic mesenteric ischemia: critical review and guidelines for management.

              CMI is caused by chronic occlusive disease of mesenteric arteries. In such an uncommon disease, clear recommendations are strongly needed. Unfortunately, treatment options for symptomatic CMI are still controversial and no guidelines exist.

                Author and article information

                Int J Surg Case Rep
                Int J Surg Case Rep
                International Journal of Surgery Case Reports
                01 July 2016
                01 July 2016
                : 25
                : 207-211
                [a ]Lisbon Medical Academic Centre, Portugal
                [b ]Hospital Santa Maria (CHLN), Lisboa, Portugal
                [c ]Faculty of Medicine, University of Lisbon, Portugal
                Author notes
                [* ]Corresponding author at: Hospital Santa Maria (CHLN), Lisboa, Serviço de Cirurgia Vascular Hospital de Santa Maria, Avenida Prof. Egas Moniz, 1649-035 Lisboa, Portugal.Hospital Santa Maria (CHLN)LisboaPortugal ryan@
                © 2016 The Authors

                This is an open access article under the CC BY-NC-ND license (

                Case Report


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