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Immunocompromised patients with hematologic malignancies, particularly those treated with anti-CD20 antibodies such as rituximab and obinutuzumab, are known to be at risk of prolonged infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Prolonged administration or combination therapy with antiviral medications reportedly yields favorable outcomes in these patients. However, knowledge regarding the adverse events associated with such therapeutic approaches is limited. Herein, we report a case of acute acalculous cholecystitis (AAC) following extended administration of nirmatrelvir/ritonavir (NMV/r) in a 68-year-old Japanese man with persistent SARS-CoV-2 infection. The patient had received obinutuzumab and bendamustine for follicular lymphoma and was diagnosed with coronavirus disease 2019 (COVID-19) approximately one year after treatment initiation with these drugs. Subsequently, he was admitted to a different hospital, where he received antiviral drugs, monoclonal antibodies, and steroids. Despite these interventions, the patient relapsed and was subsequently transferred to our hospital due to persistent SARS-CoV-2 infection. Remdesivir administration was ineffective, leading to the initiation of extended NMV/r therapy. One week later, he exhibited elevated gamma-glutamyl transpeptidase (GGT) levels, and one month later, he developed AAC. Cholecystitis was successfully resolved via percutaneous transhepatic gallbladder drainage and administration of antibiotics. We speculate that extended NMV/r administration, in addition to COVID-19, may have contributed to the elevated GGT and AAC. During treatment of persistent SARS-CoV-2 infection with extended NMV/r therapy, patients should be carefully monitored for the appearance of findings suggestive of biliary stasis and the development of AAC. [ABSTRACT FROM AUTHOR]

Right upper quadrant abdominal pain and elevated cholestasis blood tests are usually associated with bacterial calculous cholecystitis. However, viral infections, such as Epstein-Barr virus (EBV) can also manifest with a similar clinical picture and is an important differential diagnosis. This case report discusses a young woman presenting to the emergency department with acute right upper quadrant abdominal pain. The initial assessment revealed a positive Murphy's sign, elevated white blood count, and a cholestatic pattern on liver function tests, leading one to suspect bacterial calculous cholecystitis and initiating antibiotic therapy. However, clinical examination also revealed tonsillar exudates and differential white blood cell count revealed monocytosis and lymphocytosis rather than a high neutrophil count. The patient tested positive for EBV. Furthermore, ultrasound and magnetic resonance imaging revealed gallbladder wall edema with no gallstones, leading one to conclude that the clinical manifestation and laboratory results were due to an EBV infection. Antibiotic therapy was ceased and the patient did not require surgical intervention. Calculous bacterial cholecystitis usually entails antibiotic therapy and cholecystectomy. It is important to be aware of the differential diagnosis of EBV, as it usually does not require either of these and resolves spontaneously. [ABSTRACT FROM AUTHOR]

acute acalculous cholecystitis (AAC) is defined as gallbladder inflammation without the presence of stones. Contrary, hepatitis A virus (HAV) can present with different symptoms; however, HAV causing and presenting as AAC is rare. 41-year-old previously healthy patient presented with right upper quadrant abdominal pain. The pain was persistent and associated with vomiting and laboratory tests showed elevated bilirubin. Laparoscopic cholecystectomy showed inflamed gallbladder with no stones and intraoperative cholangiography showed no abnormalities. Day one post-operation, while the pain resolved, labs showed elevated liver function tests and hepatitis workup showed acute HAV infection attributing her presentation to HAV induced AAC. AAC is usually caused by stasis of the gallbladder due to different causes; however, HAV induced AAC has been rarely reported. While cholecystectomy is the mainstay treatment for AAC, this might not be the case for HAV induced AAC. For instance, unless there is necrotic gallbladder or persistence of symptoms, AAC can be managed conservatively in this case. Even though our diagnosis was cleared post-operatively, had we knew the diagnosis of HAV induced AAC before, we would have still opt for surgery due to the severity and persistence of pain. More cases should be reported and more studies should be done to further define the presentation and management of HAV induced AAC. • Hepatitis A virus as acute acalculous cholecytitis cause has been rarely reported. • Cholecystectomy might not be the treatment when cholecytitis is caused by hepatitis A virus. • Hepatitis A induced acute acalculous cholecystitis can be managed conservatively. • More cases should be reportedto further define the management of hepatitis A induced acute acalculous cholecystitis. [ABSTRACT FROM AUTHOR]

Gallbladder volvulus is a rare disease whose presentation usually overlaps with that of typical calculous cholecystitis. It's diagnosis is critical as it is associated with high morbidity and mortality and therefore should be managed urgently with cholecystectomy. 85-year-old female patient presented with right upper quadrant pain of one day duration that is associated with nausea and vomiting, but no fever or jaundice. She was tachycardiac and had severe abdominal right upper quadrant tenderness with positive Murphy's sign. Laboratory results showed only increase in inflammatory markers. Both ultrasound and computed tomography scan of the abdomen were done and acalculous cholecystitis was diagnosed. Open cholecystectomy was planned and performed, but gallbladder volvulus as the cause of cholecystitis was noted intraoperatively. There is still no consensus on the exact cause of gallbladder volvulus. Even though it presents mostly in elderly patients, different ages have been already reported. It's diagnosis can be suspected based on the appearance, symptoms, and examination of the patient. Laboratory tests and imaging might provide some clues for it's diagnoses. It's ischemic process prompts urgent surgical intervention and does not improve conservatively. Our patient did not present with all of it's typical symptoms and the diagnosis was made intraoperatively. Gallbladder volvulus could have been missed had we not opt for an urgent surgery. More studies should be done to further define its presentation, and accurately know when to consider it up in our differential diagnosis. • Gallbladder volvulus is a rare disease whose presentation overlaps with typical calculous cholecystitis. • Gallbladder volvulus diagnosis can be suspected based on the appearance, symptoms, and examination of the patient. • Gallbladder volvulus ischemic process prompts urgent surgical intervention and does not improve conservatively. • Gallbladder volvulus should be further studied to define it and know when to consider it in our different diagnosis. [ABSTRACT FROM AUTHOR]

Congenital absence of the common bile duct (CBD), also known as “cholecystohepatic duct” or “interposition of the gallbladder” is a rare extrahepatic biliary anomaly characterized by the hepatic ducts entering the gallbladder directly and the cystic duct draining the entire biliary tree into the duodenum. There have been only been four reports of children with congenital absence of the CBD, with three of these also carrying a diagnosis of esophageal atresia, suggesting an association between the two entities. We report an additional case of a child with a history of tracheoesophageal fistula and congenital absence of the CBD as well a review of the literature. [ABSTRACT FROM AUTHOR]

Acute acalculous cholecystitis has been associated with critically ill and elderly patients. In the pediatric population, the etiology of this pathology could be an uncommon but potentially significant complication of Epstein-Barr virus infection. This virus is very common in young adults and is associated with fatigue, muscle aches, fever, and in some instances can present with transaminitis and jaundice. This transient hepatocellular injury could lead to gallbladder inflammation. We are going to present our experience and treatment in two patients that presented with abdominal pain and a positive mononucleosis test. [ABSTRACT FROM AUTHOR]

Biliary disease in children has changed over the past few decades, with a marked rise in incidence-perhaps most related to the parallel rise in pediatric obesity-as well as a rise in cholecystectomy rates. In addition to stone disease (cholelithiasis), acalculous causes of gallbladder pain such as biliary dyskinesia, also appear to be on the rise and present diagnostic and treatment conundrums to surgeons. [ABSTRACT FROM AUTHOR]

Introduction Gallbladder torsion is a rare condition of increasing prevalence in recent years. It is often difficult to diagnose pre-operatively and delayed intervention can lead to significant complications. Presentation of case We present a case of an 81 year old lady who presented with symptoms of cholecystitis for 24 h with no evidence of cholelithiasis on imaging. She deteriorated within 24 h of admission despite intravenous antibiotics; Emergency laparoscopy was performed which showed the gallbladder malrotated 180 ° with features of necrosis. Laparoscopic cholecystectomy was performed without complications. Discussion The cause of gallbladder torsion are thought to be due to underlying anatomical variations or loss of elasticity associated with aging. Diagnosis is difficult clinically and radiologically, however, features such as “whirl sign” and “cystic duct knot sign” have been described. Due to ischemia associated with torsion, clinical vigilance and early intervention is recommended to prevent potential fatal sequelae particularly in the elderly population. Conclusion Gallbladder torsion is a rare finding that can be difficult to diagnose clinically, we are hoping to promote awareness to prevent complications associated with delayed therapy. [ABSTRACT FROM AUTHOR]

Acute appendicitis and acute cholecystitis are among the most common diagnoses operated by general surgeons. However, synchronous appendicitis and cholecystitis have rarely been reported and most cases have been described as acalculous cholecystitis and appendicitis in early stages that are not absolutely synchronous. We report a case of a fourteen-year-old male patient who presented acute acalculous cholecystitis with gallbladder perforation at the time of a laparoscopic appendectomy for acute appendicitis. Acute acalculous cholecystitis is an acute necroinflammation of the gallbladder in the absence of gallstones. In the pathophysiology the main factor is gallbladder wall ischemia with microcirculation failure and biliary stasis. There is discussion about the coexistence of acute appendicitis with acute cholecystitis with a presumed pathophysiological relationship; however, this is not well described. In this case it was found an acute acalculous cholecystitis in advanced stages with gallbladder perforation and a synchronous presentation of acute appendicitis. The synchronous presentation of acute appendicitis and cholecystitis with its complications, such as spontaneous perforation, is rare, but should be considered as a cause of acute abdomen with a pathophysiology still unknown. [ABSTRACT FROM AUTHOR]

Summary Epstein-Barr Virus (EBV) infection can lead to infectious mononucleosis syndrome with the typical symptoms of fever, pharyngitis, and lymphadenopathy. Self-limited mild to moderate elevation of liver enzymes and hepatosplenomegaly are common. However, cholecystitis is not usually considered part of a primary EBV infection and ultrasound scan (USS) of the liver and gallbladder is not routinely performed. Acute acalculous cholecystitis (AAC) caused by etiologies other than primary EBV infection is often associated with severe illness and antibiotic treatment and surgery may be needed. We present a case with primary EBV infection and AAC and a literature review. Our patient was a 34-year-old woman with clinical, biochemical and serological signs of primary EBV infection (lymphocytes 7.6 × 10˄9/l, monocytes 2.6 × 10˄9/l, positive early antigen IgM test and 14 days later positive early antigen IgG test). During admission, increasing liver function tests indicated cholestasis (alanine aminotransferase 61 U/l, alkaline phosphatase 429 U/l and bilirubin 42 μmol/l). USS revealed a thickened gallbladder wall indicating cholecystitis but no calculus. All other microbiological tests were negative. The literature search identified 26 cases with AAC and acute EBV infection; 25 cases involved females. Sore throat was not predominant (six reported this), and all cases experienced gastrointestinal symptoms. Our and previous published cases were not severely ill and recovered without surgical drainage. In conclusion primary EBV infection should be considered in cases of AAC, especially in young women. In cases associated with EBV infection neither administration of antibiotics nor surgical drainage may be indicated. [ABSTRACT FROM AUTHOR]

Abstract: Acquired biliary diseases are far less common in children than in adults and include gallstones, acalculous cholecystitis, biliary dyskinesia, primary sclerosing cholangitis (PSC) and benign biliary strictures. Gallstones have been increasingly diagnosed in children in recent years mainly due to increasing use of ultrasonography. The etiologies of cholelithiasis are hemolytic (20%–50%), other known etiology (30%–40%) such as total parenteral nutrition, ileal disease, congenital biliary diseases and idiopathic (20%). Spontaneous resolution of gallstones is frequent in infants and hence a period of observation is recommended even for choledocholithiasis. Children with gallstones can present with typical biliary symptoms (50%), nonspecific symptoms (25%), be asymptomatic (20%) or complicated (5%–10%). Cholecystectomy is useful in children with typical biliary symptoms but is not recommended in those with non-specific symptoms. Prophylactic cholecystectomy is recommended in children with hemolytic disorders. Biliary dyskinesia is characterized by biliary colic without the presence of gallstones. Management is controversial. In PSC immunosuppressive therapy helps children with PSC with autoimmune hepatitis features. [Copyright &y& Elsevier]

Abstract: Objective: To investigate the incidence and predisposing factors of acalculous cholecystitis (AAC) in severely burned patients. Background data: Although some studies report on AAC in critically ill patients, very little is known about AAC after severe burns. Methods: We conducted a retrospective cohort study involving patients with burns admitted to the burn intensive care unit (BICU) of a university hospital. The patient cohort was divided into two groups (AAC group: burned patients with histological proven acalculous cholecystitis, n =15; Control group: population of all other burned patients admitted to the BICU, n =1225). Univariate and multivariate analyses were used to identify predisposing factors for the development of AAC. Results: Fifteen patients with acalculous cholecystitis were identified in the study period. This represents 1.2% of all significant burns admitted. Comparing the AAC group with the Control population the following patients’ characteristics, therapeutic measures and outcome parameters were significantly different in the univariate analysis: mean age (54.0 years vs. 42.0 years), BMI (28.9kg/m2 vs. 25.6kg/m2), abbreviated burn severity index (8.3 vs. 6.4), total body surface area burn deep partial thickness (12.0% vs. 6.2%) and full thickness (10.2% vs. 6.8%), concomitant inhalation injury (80.0% vs. 28.9%), sepsis (46.7% vs. 14.9%), catecholamine (100% vs. 30.4%) and antibiotic requirement (100% vs. 58.2%), non-biliary tract operations (4.9 vs. 1.5), BICU length of stay (63.4 days vs. 21.0 days), ventilator days (50.3 vs. 11.9), packed red blood cells (PRBCs) administration (70.0units vs.13.0units) and mortality (53.3% vs. 19.7%). In the multivariate analysis however, only age, the number of administered units of PRBCs and the duration of mechanical ventilation turned out to be independent predictors for the occurrence of AAC. Conclusion: AAC is a rare complication of severely burned patients and may reflect the severity of the patient’s general conditions. Predisposing factors for AAC are advanced age, the need of blood transfusions and prolonged mechanical ventilation. In the presence of these predisposing factors, early monitoring may help to detect AAC earlier and to initiate appropriate intervention. [Copyright &y& Elsevier]

The mechanisms involved in the impaired gallbladder contractile response in chronic acalculous cholecystitis are unknown. To determine the mechanisms that may lead to impaired gallbladder emptying in chronic acalculous cholecystitis, gallbladder specimens removed during hepatic resection (controls) and after cholecystectomy for chronic acalculous cholecystitis were attached to force transducers and placed in tissue baths with oxygenated Krebs solution. Electrical field stimulation (EFS) (1 to 10 Hz, 0.1 msec, 70 V) or the contractile agonists, CCK-8 (10−9 to 10−5) or K+ (80 mmol/L), were placed separately in the tissue baths and changes in tension were determined. Patients with chronic acalculous cholecystitis had a mean gallbladder ejection fraction of 12% ± 4%. Pathologic examination of all gallbladders removed for chronic acalculous cholecystitis revealed chronic cholecystitis. Spontaneous contractile activity was present in gallbladder strips in 83% of control specimens but only 29% of gallbladder strips from patients with chronic acalculous cholecystitis (P < 0.05 vs. controls). CCK-8 contractions were decreased by 54% and EFS-stimulated contractions were decreased by 50% in the presence of chronic acalculous cholecystitis (P < 0.05 vs. controls). K+-induced contractions were similar between control and chronic acalculous cholecystitis gallbladder strips. The impaired gallbladder emptying in chronic acalculous cholecystitis appears to be due to diminished spontaneous contractile activity and decreased contractile responsiveness to both CCK and EFS. ( J Gastrointest Surg 2002;6:432–437.) [ABSTRACT FROM AUTHOR]

BACKGROUND: Epstein Barr Virus (EBV) is a ubiquitous herpes virus that persists lifelong in normal humans by colonizing memory B cells. Infection during childhood is usually asymptomatic. Isolated gallbladder wall thickening or hydrops have been reported in patients with EBV infectious mononucleosis. However, acute acalculous cholecystitis is an atypical clinical presentation of primary EBV infection. We present a teenager with acute cholecystitis associated with EBV acute infection. Acute acalculous cholecystitis accounts for 2-15% of all cases of acute cholecystitis. Few cases of acute cholecystitis have been reported during the course of primary EBV infection. PRESENTATION OF CASE: A 15-year-old female who came to the JDCH ER complaining of 3 days history of mild diffuse abdominal pain associated with two episodes of emesis. She also reports headache as well as a mild cough and low grade subjective fever. Blood test results showed mild leukocytosis with significant elevation in the lymphocytes (59%), High alkaline phosphatase (221 U/I), AST (191 U/I), ALT(221 U/I) and bilirubin (Total 1.8 and direct 1.5). Abdominal US showed a contracted gallbladder with wall thickness and pericholecystic fluid. During hospital stay number 2-3 laboratory work up show a trending up in the bilirubin levels. MRCP was ordered and no abdnormalities were found. At this point Hospital stay number 3 EBV acute infection was suspected. Serum serological studies were subsequently diagnostic for this viral disease. Management was conservative and the patient was discharged asymptomatic on hospital day number six. [ABSTRACT FROM AUTHOR]

Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer. [ABSTRACT FROM AUTHOR]

Abstract: INTRODUCTION: Haemobilia is a rare cause of upper gastro-intestinal haemorrhage which can be difficult to diagnose. PRESENTATION OF CASE: We present the case of a patient who suffered from acute acalculous cholecystitis while on dual anti-platelet therapy with aspirin and clopidogrel. We describe the diagnostic and treatment challenges arising from the patient''s complicated past history and the steps leading to the diagnosis of haemobilia causing biliary obstruction and cholangitis. Our patient did not, at any point, manifest anaemia or evidence of haemorrhage. DISCUSSION: Haemobilia has a varied aetiology. To our knowledge there is no association with dual anti-platelet treatment in the literature to date. Diagnosis is difficult and relies on multiple modalities. In our patient the final diagnosis was only made in the course of open bile duct exploration. CONCLUSION: In acute biliary obstruction we recommend the consideration of haemobilia in the differential diagnosis, especially in patients with a bleeding tendency. [Copyright &y& Elsevier]

Abstract: INTRODUCTION: Acalculous cholecystitis accounts for 10–15% of cases of cholecystitis. It is often associated with critical illness and has a high morbidity and mortality. PRESENTATION OF CASE: We report an unusual case of an elderly lady who presented with acalculous cholecystitis as the herald event for subsequent fatal intestinal ischaemia. She demonstrated classical radiological features of pneumatosis coli and hepatic porto-venous gas (HPVG). DISCUSSION: The pathogenesis of acalculous cholecystitis remains uncertain but theories including biliary stasis, sepsis and ischaemia have been proposed. The gallbladder is particularly vulnerable to ischaemia which may precipitate the inflammatory process. In this case, we propose that acute acalculous cholecystitis was triggered by ischaemia and was a herald sign of the ischaemia that would later affect the entire gastrointestinal tract. We suggest that the gallbladder''s tenuous blood supply made it more vulnerable to the ischaemia that the rest of the bowel subsequently suffered from. CONCLUSION: Intramural and hepatic porto-venous gas are classical, though rarely seen, CT findings in acute intestinal ischaemia. In these situations HPVG is often associated with poor outcome. In this case the acute acalculous cholecystitis may have been a herald sign of mesenteric ischaemia. [Copyright &y& Elsevier]

The article focuses on treatment of gallstone and gall bladder disease. It says that elective cholecystectomy is indicated once a patient with gallstones becomes symptomatic while acute cholecystitis needs urgent cholecystectomy. The role of open cholecystectomy and the treatment of common duct stones are discussed.

Summary: Dengue viral infections present a significant risk during pregnancy to both mother and fetus. A young woman at 13 weeks’ gestation presented with fever and abdominal pain following a diarrheal illness after returning from Puerto Rico. Over the course of 5 days, she developed nausea, petechiae, severe thrombocytopenia, and acalculous cholecystitis. After a serologic diagnosis of acute infection with dengue virus, she was provided supportive care. An uncomplicated pregnancy led to delivery of a healthy infant at 40 weeks gestation. Travel during pregnancy to dengue-endemic areas poses a risk to both mother and fetus. Pregnancies complicated by dengue infection require close monitoring for potential maternal and fetal complications. [Copyright &y& Elsevier]

: BackgroundAcalculous cholecystitis is a controversial entity that accounts for 5% to 22% of cholecystectomies in some series. Multiple attempts have been made to find an objective clinical algorithm for diagnosis; however, we postulate that careful evaluation of clinical presentation is adequate to allow accurate diagnosis without reliance on ancillary tests, such as cholecystokinin-stimulated scintigraphy studies.: MethodsA retrospective chart review was made of all patients who underwent laparoscopic cholecystectomy at Cariboo Memorial Hospital between April 1997 and September 2001. Patients with history and physical examination consistent with biliary colic/cholecystitis, with negative ultrasonography scans, were reviewed and a telephone survey was conducted to determine subjective clinical outcomes.: ResultsEighty-eight patients were eligible for the study. Age range was 19 to 78 years. Eighty-three percent were female and 17% were male. Seventy-eight percent of patients had chronic symptoms, 17% acute, and 5% acute on chronic. Pathology reports indicated that 92% of gallbladders revealed disease and 8% were reported as normal. Two percent of patients had major complications postoperatively and 9% had minor complications. No deaths had occurred. Seventy-eight percent of procedures were performed as day surgeries, with an average hospital stay of 1.3 days. Mean follow-up was 25 months, with a range of 3 to 55 months. Ninety-one percent of patients were available for telephone survey follow-up. Forty-one percent of patients reported being “very satisfied” with the outcome of their surgery, 52% were “satisfied,” and 4% were “not satisfied.”: ConclusionsAcalculous cholecystitis is an entity that can be satisfactorily diagnosed by detailed history and physical examination with high patient satisfaction achieved after surgical management. [Copyright &y& Elsevier]

A 71-year-old man with metastatic renal cell carcinoma presented with abdominal pain during treatment with axitinib. The diagnoses were axitinib-induced pneumatosis intestinalis (PI) and acute acalculous cholecystitis (AC). The patient's condition improved with antibiotics, bowel rest, and discontinuation of the axitinib therapy. This is the first case report in the literature. PI and AC induced by other vascular endothelial growth factor receptor tyrosine kinase inhibitors are usually self-limiting upon discontinuation of those uses, but can be life-threatening in some cases. We need to be aware of axitinib-induced PI and AC to avoid delayed or inappropriate treatments for them. [ABSTRACT FROM AUTHOR]

Abstract: This case represents a unique finding in neonates, of which there have been few reported cases. A 14 day old male presents with 10 days of vomiting and a right upper quadrant mass. Multiple imaging was performed, including abdominal ultrasounds, HIDA scan, MRCP, and eventually intra-operative cholangiogram with cholecystectomy. The patient was found to have acalculous cholecystitis and hydropic gallbladder. This case is important because recognition of this diagnosis in the neonatal is imperative due to increased risk of morbidity and mortality. Clinicians need to be aware how to appropriately diagnose and treat this uncommon disease. [ABSTRACT FROM AUTHOR]

These Guidelines have been written by the Patient Care Committee of The Society for Surgery of the Alimentary Tract (SSAT). Their goal is to guide physicians to the appropriate utilization of surgical procedures on the alimentary tract or related organs. They are based on a critical review of the literature and expert opinion. Together these sources of information result in a consensus that is recorded in the form of these Guidelines. The consensus addresses the range of acceptable clinical practice and should not be construed as a standard of care. These Guidelines will require periodic revision to ensure that clinicians utilize procedures appropriately, but the reader must realize that clinical judgment may justify a course of action outside of the recommendations contained herein. If you would like to ask a medical question, please use the SSAT Directory to find an SSAT physician in your area. [Copyright &y& Elsevier]

Summary: During the course of acute viral hepatitis, some functional and structural changes to the gallbladder can occur. Acute acalculous cholecystitis is an extremely rare complication of acute viral hepatitis. Acalculous cholecystitis associated with acute viral hepatitis can present as different conditions. Some of these are self-limiting and heal spontaneously, while a limited number of cases progress to a gangrenous state, gallbladder perforation, and even to death. We present here a case of acute acalculous cholecystitis associated with an acute hepatitis B virus infection. [Copyright &y& Elsevier]

Summary: The clinical presentation of Mycobacterium tuberculosis infection varies in patients with AIDS. We report a case of disseminated tuberculosis in an AIDS patient. The initial manifestation was masked by fluoroquinolone monotherapy, and subsequently complicated by acalculous cholecystitis and immune restoration syndrome after antiretroviral therapy. [Copyright &y& Elsevier]

Summary: Acute acalculous cholecystitis (AAC) in association with acute Epstein–Barr virus (EBV) infection has rarely been described in childhood. In the literature, there are only four reported pediatric cases of AAC associated with isolated primary EBV infection. We present two cases (one new, one retrospectively reviewed) of children with Gilbert''s syndrome (GS) who presented with AAC during the course of primary EBV infection. Antibiotics were not used and AAC subsided gradually as the infection regressed. The co-occurrence of GS might have played a contributory role in the pathogenesis of AAC during acute EBV infection. [Copyright &y& Elsevier]

Abstract: Acute acalculous cholecystitis (AAC) comprises 5% to 10% of all cases of acute cholecystitis in adults and appears to be even less frequently diagnosed in children. The diagnosis of AAC is established upon some clinical, laboratory, and ultrasonographic findings, which may sometimes be ambiguous and confusing especially in children. Diagnostic difficulties may result in either delayed diagnosis or unnecessary surgical intervention. Acute cholecystitis owing to viral infectious factors is reported to be extremely rare. The aim of the article is to demonstrate 2 cases of AAC as a clinical presentation of both Epstein-Barr virus and cytomegalovirus infection in children. [Copyright &y& Elsevier]