Acute cholecystitis resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vendhan Ramanujam M.B.B.S [2]

Overview

Cholecystitis is the inflammation of the gallbladder.

Shown below is a table summarizing the different key terms used to refer to cholecystitis.

Terms Definitions
Acute cholecystitis Acute cholecystitis is an acute inflammatory disease of the gallbladder, most often attributable to gallstones.[1][2]
Acute calculous cholecystitis Acute calculous cholecystitis is an acute inflammatory disease of the gallbladder in the presence of cholelithiasis.[1] The Tokyo guidelines are used in the diagnosis of acute calculous cholecystitis.[3][4]
Acute acalculous cholecystitis Acute acalculous cholecystitis is an acute necroinflammatory disease of the gallbladder in the absence of cholelithiasis and has a multifactorial pathogenesis.[5]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Common Causes

Management

Diagnostic Approach

Shown below is an algorithm depicting the diagnostic approach of acute cholecystitis according to the Society for Surgery of the Alimentary Tract (SSAT),[7] the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES),[8] the Tokyo guidelines for management of cholecystitis,[9] and review of data from multiple studies on acalculous cholecystitis.[5]

 
 
 
 
 
 
Characterize the symptoms:

Symptoms suggestive of calculous or acalculous cholecystitis:
❑ Acute RUQ or epigastric pain

❑ Sharp, severe and steady
❑ Duration >6 hours
❑ Radiation to right shoulder blade
❑ Following food intake
❑ Aggravated by movements
❑ Associated with
Nausea & vomiting
Diaphoresis
Fever
Anorexia
❑ Mass in the RUQ
❑ Symptoms suggestive of sepsis
❑ Symptoms suggestive of common hepatic duct obstruction
❑ RUQ pain with fever & jaundice
❑ Symptoms suggestive of gallstone ileus
❑ Transient abdominal pain with nausea & vomiting
Hematemesis

OR
Atypical symptoms suggestive of acalculous cholecystitis:
❑ Acute vague abdominal pain

❑ Associated with
❑ RUQ mass
❑ Jaundice
❑ Fever
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
Fever
❑ Jaundice
❑ Dehydration
❑ Tachycardia
❑ RUQ mass
Abdominal guarding
Murphy's sign
❑ Abdominal crepitations
❑ Abdominal tenderness
❑ Reduced bowel sounds
❑ Increased bowel sounds
Abdominal distension
Signs of sepsis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnoses:
Acute hepatitis
Acute pancreatitis
Appendicitis
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:
CBC
❑ BMP
CRP
❑ Total bilirubin
❑ Direct bilirubin
Albumin
AST
ALT
Alkaline phosphatase
GGT
Amylase
Lipase
Order urgent transabdominal USG (TAUSG)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider the diagnostic criteria of acute calculous cholecystitis:[3][4]
❑ Local symptoms & signs
Murphy’s sign
❑ Pain or tenderness in RUQ
❑ Mass in RUQ

❑ Systemic signs

❑ Fever
❑ Leukocytosis
❑ Elevated CRP

❑ Imaging findings

TAUSG
HIDA scan
 
 
 
Consider the diagnostic criteria of acute acalculous cholecystitis:[5]
❑ Acute abdominal pain
❑ Fever
❑ Leukocytosis
❑ Abnormal liver function tets
❑ Imaging based criteria
TAUSG based criteria
HIDA scan based criteria
CT based criteria
 
 

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

Treatment Approach

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),[7] the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES),[8] the Tokyo guidelines for management of cholecystitis,[9] and review of data from multiple studies on acalculous cholecystitis.[5]

Acute Calculous Cholecystitis

 
 
 
 
 
 
Acute calculous cholecystitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Hospital admission
❑ NPO
❑ IVF & correct electrolyte abnormalities
❑ Empiric IV antibiotics[10]
Ceftriaxone 1 g IV every 24 hours/2 g IV every 12 hours for CNS infections
+
Metronidazole 500 mg IV every 8 hours

or

Ciprofloxacin 400 mg IV every 12 hours
or
Levofloxacin 500 or 750 mg IV once daily
+
Metronidazole 500 mg IV every 8 hours
❑ Acute pain management
Ketorolac 30-60 mg IM/IV single dose

or

Opioids until cholecystectomy if ketorolac is contraindicated/pain not improving
Assess severity[4]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
With complications:
❑ Emergency cholecystectomy + blood C&S ± bile C&S
❑ Consider appropriate surgeries for gallstone ileus & Mirizzi syndrome
 

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
 

Do's

  • 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.[10]
  • 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.

Dont's

  • 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).

References

  1. 1.0 1.1 Strasberg, SM. (2008). "Clinical practice. Acute calculous cholecystitis.". N Engl J Med. 358 (26): 2804–11. PMID 18579815. doi:10.1056/NEJMcp0800929.  Unknown parameter |month= ignored (help)
  2. 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. 
  3. 3.0 3.1 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. 
  4. 4.0 4.1 4.2 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. 
  5. 5.0 5.1 5.2 5.3 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.  Unknown parameter |month= ignored (help)
  6. 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. 
  7. 7.0 7.1 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.  Unknown parameter |month= ignored (help)
  8. 8.0 8.1 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.  Unknown parameter |month= ignored (help)
  9. 9.0 9.1 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.  Unknown parameter |month= ignored (help)
  10. 10.0 10.1 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.  Unknown parameter |month= ignored (help)

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