Although cholecystectomy is generally recommended for acute acalculous cholecystitis (AAC) treatment, non-surgical management can be considered in patients at a high risk for surgery. This study compared outcomes of surgical and non-surgical management and analyzed the long-term outcomes of AAC patients managed non-surgically.We retrospectively analyzed 89 patients diagnosed with AAC between January 1, 2007 and April 30, 2014. These patients were divided into 2 groups: non-surgical (n = 41) and surgical (n = 48). Non-surgical management methods were percutaneous cholecystostomy (PC, n = 14) and antibiotics only (n = 27). The non-surgical group was followed up for >3 years after treatment.The mean age was slightly higher in the non-surgical group than in the surgical group without significant difference. The prevalence of cerebrovascular accident in the non-surgical group was significantly higher than that in the surgical group (26.8% vs 8.3%, P = .020). Mean hospital stay was not statistically different between two groups. The surgical group had a significantly higher incidence of posttreatment complications than the non-surgical group (18.8% vs 2.4%, P = .015). During the mean follow-up of 5.7 years, AAC recurred in 4 (9.8%) patients in the non-surgical group. Three patients underwent cholecystectomy, 1 was treated with antibiotics, and no recurrence-related death occurred. The recurrence rate of AAC was not different between PC and antibiotics only groups (14.3% vs 7.4%, P = .596).Recurrence was observed in 9.8% of AAC patients treated non-surgically and the outcome in the non-surgical group was not inferior to that in the surgical group.