Acute cholecystitis resident survival guide
Cholecystitis is the inflammation of the gallbladder.
Shown below is a table summarizing the different key terms used to refer to cholecystitis.
|Acute cholecystitis||Acute cholecystitis is an acute inflammatory disease of the gallbladder, most often attributable to gallstones.|
|Acute calculous cholecystitis||Acute calculous cholecystitis is an acute inflammatory disease of the gallbladder in the presence of cholelithiasis. The Tokyo guidelines are used in the diagnosis of acute calculous cholecystitis.|
|Acute acalculous cholecystitis||Acute acalculous cholecystitis is an acute necroinflammatory disease of the gallbladder in the absence of cholelithiasis and has a multifactorial pathogenesis.|
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
Shown below is an algorithm depicting the diagnostic approach of acute cholecystitis according to the Society for Surgery of the Alimentary Tract (SSAT), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the Tokyo guidelines for management of cholecystitis, and review of data from multiple studies on acalculous cholecystitis.
Characterize the symptoms:
Symptoms suggestive of calculous or acalculous cholecystitis:
Consider alternative diagnoses:
❑ Acute hepatitis
❑ Acute pancreatitis
❑ Biliary colic
❑ Cardiac ischemia
❑ Diseases of the right kidney
❑ Fitz-Hugh-Curtis syndrome
❑ Functional gallbladder disorder
❑ Irritable bowel disease
❑ Nonulcer dyspepsia
❑ Peptic ulcer disease
❑ Perforated viscus
❑ Right-sided pneumonia
❑ Sphincter of Oddi dysfunction
❑ Subhepatic or intraabdominal abscess
|Gallbladder stones with gallbladder edema||Gallbladder stones without gallbladder edema, or |
Gallbladder edema without gallbladder stones
|No gallbladder stones and no gallbladder edema|
|❑ HIDA scan||❑ Consider evaluation for alternate diagnosis of abdominal pain|
|Gallbladder opacity not visualized||Gallbladder opacity visualized|
|❑ CT abdomen|
ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; BMP: Basic metabolic panel; CBC: Complete blood count; CRP: C-reactive protein; CT: Computed tomography; GGT: Gamma-glutamyl transpeptidase; HIDA scan: Hepatobiliary iminodiacetic acid scan; RUQ: Right upper quadrant
Shown below are algorithms depicting the treatment approach of acute calculous cholecystitis and acute acalculous cholecystitis according to the Society for Surgery of the Alimentary Tract (SSAT), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), the Tokyo guidelines for management of cholecystitis, and review of data from multiple studies on acalculous cholecystitis.
Acute Calculous Cholecystitis
|Acute calculous cholecystitis|
❑ Hospital admission
❑ IVF & correct electrolyte abnormalities
❑ Empiric IV antibiotics
|Grade 1 (Mild)||Grade 2 (Moderate)||Grade 3 (Severe)|
|❑ Cholecystectomy within 72 hours|
❑ Assess for complications and surgical risk
|❑ Emergency biliary drainage + blood C&S ± bile C&S|
❑ Cholecystectomy after 3 months if GBS found during biliary drainage
Without complications & non high risk surgical candidates:
❑ Immediate cholecystectomy + blood C&S ± bile C&S
Without complications & high risk surgical candidates:
❑ Immediate biliary drainage + blood C&S ± bile C&S
CNS: Central nervous system; C&S: Culture & sensitivity; GBS: Gallbladder stone; IV: Intravenous; IVF: Intravenous fluids; NPO: Nil per oral
Acute Acalculous Cholecystitis
|Acute acalculous cholecystitis|
|❑ Immediate biliary drainage|
|❑ Patient improves||❑ Patient does not improve|
❑ Urgent cholecystectomy
- Administer antibiotics if infection is suspected on the basis of laboratory and clinical findings (>12,500 white cells/mm 3 or temperature >38.5°C) and radiographic findings (e.g., air in the gallbladder or gallbladder wall) as per the Infectious Diseases Society of America recommendation.
- Administer prophylactic antibiotics before surgery among high risk patients characterized by age >60 years, presence of diabetes, acute colic within 30 days of operation, jaundice, acute cholecystitis, or cholangitis (Level I, Grade B).
- Limit the prophylactic antibiotics to a single preoperative dose given within 1 hour of skin incision (Level II, Grade A).
- Early laparoscopic cholecystectomy is the preferred approach and should be done in patients with acute cholecystitis (Level II, Grade B).
- Radiographically guided percutaneous cholecystostomy is the effective method of biliary drainage and should be done in critically ill patients with acute cholecystitis, until the patient recovers sufficiently to undergo cholecystectomy (Level II, Grade B).
- Determine the time to discharge after surgery for patients with acute cholecystitis on an individual basis (Level III, Grade A).
- Consider evaluating the patient for choledocholithiasis and cholangitis if the patient has significantly elevated total bilirubin, alkaline phosphatase, ALT, AST and/or GGT.
- Do not administer antibiotics among low-risk patients undergoing laparoscopic cholecystectomy (Level I, Grade A).
- Do not place a drain after elective laparoscopic cholecystectomy because the use of drains may increase complication rates. (Level I, Grade A).
- Strasberg, SM. (2008). "Clinical practice. Acute calculous cholecystitis.". N Engl J Med. 358 (26): 2804–11. PMID 18579815. doi:10.1056/NEJMcp0800929.
- Reiss, R.; Deutsch, AA. (1993). "State of the art in the diagnosis and management of acute cholecystitis.". Dig Dis. 11 (1): 55–64. PMID 8443956.
- Takada, T.; Kawarada, Y.; Nimura, Y.; Yoshida, M.; Mayumi, T.; Sekimoto, M.; Miura, F.; Wada, K.; Hirota, M. (2007). "Background: Tokyo Guidelines for the management of acute cholangitis and cholecystitis.". J Hepatobiliary Pancreat Surg. 14 (1): 1–10. PMID 17252291. doi:10.1007/s00534-006-1150-0.
- Hirota, M.; Takada, T.; Kawarada, Y.; Nimura, Y.; Miura, F.; Hirata, K.; Mayumi, T.; Yoshida, M.; Strasberg, S. (2007). "Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines.". J Hepatobiliary Pancreat Surg. 14 (1): 78–82. PMID 17252300. doi:10.1007/s00534-006-1159-4.
- Huffman, JL.; Schenker, S. (2010). "Acute acalculous cholecystitis: a review.". Clin Gastroenterol Hepatol. 8 (1): 15–22. PMID 19747982. doi:10.1016/j.cgh.2009.08.034.
- Kimura, Y.; Takada, T.; Kawarada, Y.; Nimura, Y.; Hirata, K.; Sekimoto, M.; Yoshida, M.; Mayumi, T.; Wada, K. (2007). "Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines.". J Hepatobiliary Pancreat Surg. 14 (1): 15–26. PMID 17252293. doi:10.1007/s00534-006-1152-y.
- Duncan, CB.; Riall, TS. (2012). "Evidence-based current surgical practice: calculous gallbladder disease.". J Gastrointest Surg. 16 (11): 2011–25. PMID 22986769. doi:10.1007/s11605-012-2024-1.
- Overby, DW.; Apelgren, KN.; Richardson, W.; Fanelli, R.; Overby, DW.; Apelgren, KN.; Beghoff, KR.; Curcillo, P.; Awad, Z. (2010). "SAGES guidelines for the clinical application of laparoscopic biliary tract surgery.". Surg Endosc. 24 (10): 2368–86. PMID 20706739. doi:10.1007/s00464-010-1268-7.
- Mayumi, T.; Someya, K.; Ootubo, H.; Takama, T.; Kido, T.; Kamezaki, F.; Yoshida, M.; Takada, T. (2013). "Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis.". J UOEH. 35 (4): 249–57. PMID 24334691.
- Solomkin, JS.; Mazuski, JE.; Baron, EJ.; Sawyer, RG.; Nathens, AB.; DiPiro, JT.; Buchman, T.; Dellinger, EP.; Jernigan, J. (2003). "Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections.". Clin Infect Dis. 37 (8): 997–1005. PMID 14523762. doi:10.1086/378702.