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| __NOTOC__ | | __NOTOC__ |
| {{CMG}}; {{AE}} {{VR}}
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| ==Definitions==
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| Cholecystitis is the inflammation of the gallbladder.<br>
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| Shown below is a table summarizing the different key terms used to refer to cholecystitis.
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| {|class="wikitable"
| | '''[[Acute cholecystitis resident survival guide|Click here for acute cholecystitis.]]''' |
| ! Terms!! Definitions
| | <br> |
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| | '''[[Chronic cholecystitis resident survival guide|Click here for chronic cholecystitis.]]''' |
| | Acute cholecystitis|| Acute cholecystitis is an acute inflammatory disease of the gallbladder, most often attributable to gallstones.<ref name="Strasberg-2008">{{Cite journal | last1 = Strasberg | first1 = SM. | title = Clinical practice. Acute calculous cholecystitis. | journal = N Engl J Med | volume = 358 | issue = 26 | pages = 2804-11 | month = Jun | year = 2008 | doi = 10.1056/NEJMcp0800929 | PMID = 18579815 }}</ref><ref name="Reiss-1993">{{Cite journal | last1 = Reiss | first1 = R. | last2 = Deutsch | first2 = AA. | title = State of the art in the diagnosis and management of acute cholecystitis. | journal = Dig Dis | volume = 11 | issue = 1 | pages = 55-64 | month = | year = 1993 | doi = | PMID = 8443956 }}</ref>
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| | Acute calculous cholecystitis|| Acute calculous cholecystitis is an acute inflammatory disease of the gallbladder in the presence of cholelithiasis.<ref name="Strasberg-2008">{{Cite journal | last1 = Strasberg | first1 = SM. | title = Clinical practice. Acute calculous cholecystitis. | journal = N Engl J Med | volume = 358 | issue = 26 | pages = 2804-11 | month = Jun | year = 2008 | doi = 10.1056/NEJMcp0800929 | PMID = 18579815 }}</ref> The [[Cholecystitis overview#Diagnostic Criteria|Tokyo guidelines]] is used in the diagnosis of acute calculous cholecystitis.<ref name="Takada-2007">{{Cite journal | last1 = Takada | first1 = T. | last2 = Kawarada | first2 = Y. | last3 = Nimura | first3 = Y. | last4 = Yoshida | first4 = M. | last5 = Mayumi | first5 = T. | last6 = Sekimoto | first6 = M. | last7 = Miura | first7 = F. | last8 = Wada | first8 = K. | last9 = Hirota | first9 = M. | title = Background: Tokyo Guidelines for the management of acute cholangitis and cholecystitis. | journal = J Hepatobiliary Pancreat Surg | volume = 14 | issue = 1 | pages = 1-10 | month = | year = 2007 | doi = 10.1007/s00534-006-1150-0 | PMID = 17252291 }}</ref><ref name="Hirota-2007">{{Cite journal | last1 = Hirota | first1 = M. | last2 = Takada | first2 = T. | last3 = Kawarada | first3 = Y. | last4 = Nimura | first4 = Y. | last5 = Miura | first5 = F. | last6 = Hirata | first6 = K. | last7 = Mayumi | first7 = T. | last8 = Yoshida | first8 = M. | last9 = Strasberg | first9 = S. | title = Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. | journal = J Hepatobiliary Pancreat Surg | volume = 14 | issue = 1 | pages = 78-82 | month = | year = 2007 | doi = 10.1007/s00534-006-1159-4 | PMID = 17252300}}</ref>
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| | Acute acalculous cholecystitis|| Acute acalculous cholecystitis is an acute necroinflammatory disease of the gallbladder in the absence of cholelithiasis and has a multifactorial pathogenesis.<ref name="Huffman-2010">{{Cite journal | last1 = Huffman | first1 = JL. | last2 = Schenker | first2 = S. | title = Acute acalculous cholecystitis: a review. | journal = Clin Gastroenterol Hepatol | volume = 8 | issue = 1 | pages = 15-22 | month = Jan | year = 2010 | doi = 10.1016/j.cgh.2009.08.034 | PMID = 19747982 }}</ref> Data from multiple studies is used for suspecting the diagnosis of acute acalculous cholecystitis.<ref name="Huffman-2010">{{Cite journal | last1 = Huffman | first1 = JL. | last2 = Schenker | first2 = S. | title = Acute acalculous cholecystitis: a review. | journal = Clin Gastroenterol Hepatol | volume = 8 | issue = 1 | pages = 15-22 | month = Jan | year = 2010 | doi = 10.1016/j.cgh.2009.08.034 | PMID = 19747982 }}</ref>
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| | Chronic cholecystitis|| Chronic cholecystitis is a chronic inflammatory disease of the gallbladder with histological evidence of chronic inflammation like large range of related inflammatory epithelial changes including mononuclear infiltrate, fibrosis, thickening of muscular layer, dysplasia, hyperplasia and metaplasia.<ref name="Zhou-2013">{{Cite journal | last1 = Zhou | first1 = D. | last2 = Guan | first2 = WB. | last3 = Wang | first3 = JD. | last4 = Zhang | first4 = Y. | last5 = Gong | first5 = W. | last6 = Quan | first6 = ZW. | title = A comparative study of clinicopathological features between chronic cholecystitis patients with and without Helicobacter pylori infection in gallbladder mucosa. | journal = PLoS One | volume = 8 | issue = 7 | pages = e70265 | month = | year = 2013 | doi = 10.1371/journal.pone.0070265 | PMID = 23936177 }}</ref>
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| ==Causes==
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| ===Life Threatening Causes===
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| Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
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| *[[Cholecystitis natural history, complications and prognosis#Gangrenous cholecystitis|Gangrenous cholecystitis]]
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|
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| ===Common Causes===
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| *[[Acalculous cholecystitis]]
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| *[[Calculous cholecystitis]]<ref name="Kimura-2007">{{Cite journal | last1 = Kimura | first1 = Y. | last2 = Takada | first2 = T. | last3 = Kawarada | first3 = Y. | last4 = Nimura | first4 = Y. | last5 = Hirata | first5 = K. | last6 = Sekimoto | first6 = M. | last7 = Yoshida | first7 = M. | last8 = Mayumi | first8 = T. | last9 = Wada | first9 = K. | title = Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. | journal = J Hepatobiliary Pancreat Surg | volume = 14 | issue = 1 | pages = 15-26 | month = | year = 2007 | doi = 10.1007/s00534-006-1152-y | PMID = 17252293 }}</ref>
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| ==Management==
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| Shown below are algorithms depicting the diagnostic and treatment approach of acute and chronic cholecystitis according to the Society for Surgery of the Alimentary Tract (SSAT),<ref name="Duncan-2012">{{Cite journal | last1 = Duncan | first1 = CB. | last2 = Riall | first2 = TS. | title = Evidence-based current surgical practice: calculous gallbladder disease. | journal = J Gastrointest Surg | volume = 16 | issue = 11 | pages = 2011-25 | month = Nov | year = 2012 | doi = 10.1007/s11605-012-2024-1 | PMID = 22986769 }}</ref> the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES),<ref name="Overby-2010">{{Cite journal | last1 = Overby | first1 = DW. | last2 = Apelgren | first2 = KN. | last3 = Richardson | first3 = W. | last4 = Fanelli | first4 = R. | last5 = Overby | first5 = DW. | last6 = Apelgren | first6 = KN. | last7 = Beghoff | first7 = KR. | last8 = Curcillo | first8 = P. | last9 = Awad | first9 = Z. | title = SAGES guidelines for the clinical application of laparoscopic biliary tract surgery. | journal = Surg Endosc | volume = 24 | issue = 10 | pages = 2368-86 | month = Oct | year = 2010 | doi = 10.1007/s00464-010-1268-7 | PMID = 20706739 }}</ref> the Tokyo guidelines for management of cholecystitis,<ref name="Mayumi-2013">{{Cite journal | last1 = Mayumi | first1 = T. | last2 = Someya | first2 = K. | last3 = Ootubo | first3 = H. | last4 = Takama | first4 = T. | last5 = Kido | first5 = T. | last6 = Kamezaki | first6 = F. | last7 = Yoshida | first7 = M. | last8 = Takada | first8 = T. | title = Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis. | journal = J UOEH | volume = 35 | issue = 4 | pages = 249-57 | month = Dec | year = 2013 | doi = | PMID = 24334691 }}</ref> and review of data from multiple studies on acalculous cholecystitis.<ref name="Huffman-2010">{{Cite journal | last1 = Huffman | first1 = JL. | last2 = Schenker | first2 = S. | title = Acute acalculous cholecystitis: a review. | journal = Clin Gastroenterol Hepatol | volume = 8 | issue = 1 | pages = 15-22 | month = Jan | year = 2010 | doi = 10.1016/j.cgh.2009.08.034 | PMID = 19747982 }}</ref>
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|
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| ===Diagnostic Approach===
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| ====Acute Cholecystitis====
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| {{familytree/start |summary=Cholecystitis}}
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| {{familytree | | | | | | | | A01 | | | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:'''<br>❑ Acute RUQ or epigastric pain<br>
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| :❑ Sharp, severe and steady
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| :❑ For >6 hours
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| :❑ Radiating to right shoulder blade
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| :❑ After food intake
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| :❑ Aggravated by movements
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| :❑ Associated with
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| ::❑ [[Nausea]] & [[vomiting]]
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| ::❑ [[Diaphoresis]]
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| ::❑ [[Fever]]
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| ::❑ [[Anorexia]]
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| ::❑ Mass in the RUQ
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| ::❑ Sx suggestive of [[Sepsis history and symptoms|sepsis]]
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| ::❑ Sx suggestive of [[Mirizzi's syndrome|common hepatic duct obstruction]]
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| :::❑ RUQ pain with fever & [[jaundice]]
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| ::❑ Sx suggestive of [[gallstone ileus]]
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| :::❑ Transient abdominal pain with nausea & vomiting
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| :::❑ [[Hematemesis]]<br>
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| ❑ Acute vague abdominal pain
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| :❑ Associated with
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| ::❑ RUQ mass
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| ::❑ Jaundice
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| ::❑ Fever</div>}}
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| {{familytree | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | B01 | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:'''<BR>❑ [[Febrile]]<BR>❑ Jaundice<BR>❑ Dehydrated<BR>❑ Tachycardia<BR>❑ RUQ mass<BR>❑ [[Abdominal guarding]]<BR>❑ [[Murphy's sign]]<BR>❑ Abdominal crepitations<BR>❑ Abdominal tenderness<BR>❑ Reduced bowel sounds<BR>❑ Increased bowel sounds<BR>❑ [[Abdominal distension]]<BR>❑ [[Sepsis physical examination|Signs of sepsis]]</div>}}
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| {{familytree | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | C01 | | | | | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Probable diagnosis:'''<BR>❑ Acute calculous cholecystitis<BR>❑ Acute acalculous cholecystitis
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| ----
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| '''Differential diagnosis'''<BR>❑ [[Acute hepatitis]]<BR>❑ [[Acute pancreatitis]]<BR>❑ [[Appendicitis]]<BR>❑ [[Biliary colic]]<BR>❑ [[Angina|Cardiac ischemia]]<BR>❑ Diseases of the right kidney<BR>❑ [[Fitz-Hugh-Curtis syndrome]]<BR>❑ Functional gallbladder disorder<BR>❑ [[Irritable bowel disease]]<BR>❑ [[Nonulcer dyspepsia]]<BR>❑ [[Peptic ulcer disease]]<BR>❑ Perforated viscus<BR>❑ [[Pneumonia|Right-sided pneumonia]]<BR>❑ Sphincter of Oddi dysfunction<BR>❑ [[Subphrenic abscess|Subhepatic]] or intraabdominal abscess</div>}}
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| {{familytree | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | D01 | | | | | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br>❑ CBC<br>❑ BMP<br>❑ CRP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase
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| ----
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| '''Order urgent transabdominal USG (TAUSG)'''</div>}}
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| {{familytree | | |,|-|-|-|-|-|+|-|-|-|-|-|.| | |}}
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| {{familytree | | E01 | | | | E02 | | | | E03 | |E01=GBS w/ GB edema|E02=GBS w/o GB edema/GB edema w/o GBS|E03=No GBS/GB edema}}
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| {{familytree | | |!| | | | | |!| | | | | |!| | |}}
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| {{familytree | | |!| | | | | F01 | | | | F02 | |F01=HIDA scan|F02=[[Abdominal pain resident survival guide|Consider evaluation for alternate diagnosis of abdominal pain]]}}
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| {{familytree | | |!| | | |,|-|^|-|.| | | | | | |}}
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| {{familytree | | G01 |-| G02 | | G03 | | | | | |G01=<div style="float: left; text-align: left; line-height: 150% ">'''[[Cholecystitis overview#Diagnostic Criteria|Diagnostic criteria]]''':<ref name="Takada-2007">{{Cite journal | last1 = Takada | first1 = T. | last2 = Kawarada | first2 = Y. | last3 = Nimura | first3 = Y. | last4 = Yoshida | first4 = M. | last5 = Mayumi | first5 = T. | last6 = Sekimoto | first6 = M. | last7 = Miura | first7 = F. | last8 = Wada | first8 = K. | last9 = Hirota | first9 = M. | title = Background: Tokyo Guidelines for the management of acute cholangitis and cholecystitis. | journal = J Hepatobiliary Pancreat Surg | volume = 14 | issue = 1 | pages = 1-10 | month = | year = 2007 | doi = 10.1007/s00534-006-1150-0 | PMID = 17252291 }}</ref><ref name="Hirota-2007">{{Cite journal | last1 = Hirota | first1 = M. | last2 = Takada | first2 = T. | last3 = Kawarada | first3 = Y. | last4 = Nimura | first4 = Y. | last5 = Miura | first5 = F. | last6 = Hirata | first6 = K. | last7 = Mayumi | first7 = T. | last8 = Yoshida | first8 = M. | last9 = Strasberg | first9 = S. | title = Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. | journal = J Hepatobiliary Pancreat Surg | volume = 14 | issue = 1 | pages = 78-82 | month = | year = 2007 | doi = 10.1007/s00534-006-1159-4 | PMID = 17252300 }}</ref><br>❑ Local symptoms & signs
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| :❑ [[Murphy’s sign]]
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| :❑ Pain or tenderness in RUQ
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| :❑ Mass in RUQ<br>
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| ❑ Systemic signs
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| :❑ Fever
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| :❑ Leukocytosis
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| :❑ Elevated CRP<br>
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| ❑ Imaging findings
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| :❑ [[Cholecystitis ultrasound#Calculous Cholecystitis|TAUSG]]
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| :❑ [[Cholecystitis other diagnostic studies#Calculous Cholecystitis|HIDA scan]]</div>|G02=GB opacity not visualized|G03=GB opacity visualized}}
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| {{familytree | | |!| | | | | | | |!| | | | | | | |}}
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| {{familytree | | |)|-|-| H01 | | H02 | | | | | | |H01=W/ significantly elevated total bilirubin, alkaline phosphatase, ALT, AST &/or GGT|H02=CT abdomen}}
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| {{familytree | | |!| | | |!| | | |!| | | | | | | |}}
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| {{familytree | | I01 | | I02 | | I03 | | | | | | |I01='''Acute calculous cholecystitis'''<br>w/ or w/o complications|I02=Consider evaluation for alternate diagnosis like [[choledocholithiasis]] & [[cholangitis]]|I03=<div style="float: left; text-align: left; line-height: 150% ">'''Diagnostic criteria:'''<ref name="Huffman-2010">{{Cite journal | last1 = Huffman | first1 = JL. | last2 = Schenker | first2 = S. | title = Acute acalculous cholecystitis: a review. | journal = Clin Gastroenterol Hepatol | volume = 8 | issue = 1 | pages = 15-22 | month = Jan | year = 2010 | doi = 10.1016/j.cgh.2009.08.034 | PMID = 19747982 }}</ref><BR>❑ Acute abdominal pain<BR>❑ Fever<BR>❑ Leukocytosis<BR>❑ Abnormal liver function tets<BR>❑ Imaging based criteria
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| :❑ [[Cholecystitis ultrasound#Imaging Criteria for Acalculous Cholecystitis|TAUSG based]]
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| :❑ [[Cholecystitis other diagnostic studies#Imaging Criteria for Acalculous Cholecystitis|HIDA scan based]]
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| :❑ [[Cholecystitis CT#Imaging Criteria for Acalculous Cholecystitis|CT based criteria]]</div>}}
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| {{familytree | | | | | | | | | | |!| | | | | | | |}}
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| {{familytree | | | | | | | | | | J01 | | | | | | |J01=Suspect '''acute acalculous cholecystitis'''}}
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| {{familytree/end}}
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| '''ALT:''' Alanine aminotransferase; '''AST:''' Aspartate aminotransferase; '''BMP:''' Basic metabolic profile; '''CBC:''' Complete blood count; '''CRP:''' C-reactive protein; '''CT:''' Computed tomography; '''GB:''' Gallbladder; '''GBS:''' Gallbladder stone; '''GGT:''' Gamma-glutamyl transpeptidase; '''HIDA scan:''' Hepatobiliary iminodiacetic acid scan; '''RUQ:''' Right upper quadrant; '''Sx:''' Symptom; '''W/:''' With; '''W/O:''' Without
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|
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| ====Chronic Cholecystitis====
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| {{familytree/start |summary=Cholecystitis}}
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| {{familytree | | | | | | | | A01 | | | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:'''<br>❑ Recurrent biliary type abdominal pain w/ or w/o fever<br>❑ Recurrent abdominal bloating<br>❑ Unstable stool with [[constipation]]/[[diarrhea]]<br>❑ Weight loss</div>}}
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| {{familytree | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | B01 | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:'''<BR>❑ [[Febrile]]<BR>❑ [[Jaundice]]<BR>❑ [[Murphy's sign]]<BR>❑ Nonspecific finding</div>}}
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| {{familytree | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | C01 | | | | | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Probable diagnosis:'''<br>❑ Chronic cholecystitis
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| ----
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| '''Differential diagnosis'''<BR>❑ [[Biliary colic]]<BR>❑ [[Cholangiocarcinoma]]<BR>❑ [[Choledocholithiasis]]<BR>❑ [[Cholelithiasis]]<BR>❑ [[Gallbladder cancer]]<BR>❑ Gallbladder mucocele<BR>❑ [[Peptic ulcer disease]]</div>}}
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| {{familytree | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | D01 | | | | | | | |D01=<div style="float: left; text-align: left; line-height: 150% ">'''Order laboratory tests:'''<br>❑ CBC<br>❑ BMP<br>❑ CRP<br>❑ Total bilirubin<br>❑ Direct bilirubin<br>❑ Albumin<br>❑ AST<br>❑ ALT<br>❑ Alkaline phosphatase<br>❑ GGT<br>❑ Amylase<br>❑ Lipase
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| ----
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| '''Order imaging studies:'''<br>❑ [[Cholecystitis ultrasound#Chronic Calculous and Acalculous Cholecystitis|TAUSG]]<BR>❑ [[Cholecystitis CT#Chronic Calculous and Acalculous Cholecystitis|CT abdomen]]<br>❑ [[Cholecystitis other diagnostic studies#Chronic Cholecystitis|HIDA scan]]<br>❑ [[Cholecystitis other diagnostic studies#Chronic Cholecystitis|Cholecystokinin stimulated HIDA scan]]</div>}}
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| {{familytree | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | E01 | | | | | | | |E01=<div style="float: left; text-align: left; line-height: 150% ">'''Diagnostic criteria:'''<BR>❑ Chronic biliary Sx<BR>❑ Absence of other pain sources during CT<BR>❑ Stone-free TAUSG<br>❑ Delayed GB isotope accumulation, irregular GB filling, or photopenic areas and septations during HIDA cholescintigraphy<BR>❑ Low EF (<35%) in cholecystokinin stimulated HIDA scan</div>}}
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| {{familytree | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | F01 | | | | | | | |F01='''Suspect chronic cholecystitis'''}}
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| {{familytree/end}}
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| '''ALT:''' Alanine aminotransferase; '''AST:''' Aspartate aminotransferase; '''BMP:''' Basic metabolic profile; '''CBC:''' Complete blood count; '''CRP:''' C-reactive protein; '''CT:''' Computed tomography; '''EF:''' Ejection fraction; '''GB:''' Gallbladder; '''GGT:''' Gamma-glutamyl transpeptidase; '''HIDA scan:''' Hepatobiliary iminodiacetic acid scan; '''Sx:''' Symptom; '''TAUSG:''' Transabdominal ultrasonography; '''W/:''' With; '''W/O:''' Without
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|
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| ===Treatment Approach===
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| ====Acute Cholecystitis====
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| {{familytree/start |summary=Cholecystitis}}
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| {{familytree | | | | | | | | | A01 | | | | | | | | | | | |A01='''Acute cholecystitis'''}}
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| {{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | | |}}
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| {{familytree | | B01 | | | | | | | | | | | | B02 | | | | |B01='''Acute calculous cholecystitis'''<br>w/ or w/o complications|B02='''Acute acalculous cholecystitis'''}}
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| {{familytree | | |!| | | | | | | | | | | | | |!| | | | | |}}
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| {{familytree | | C01 | | | | | | | | | | | | C02 | | | ||C01=<div style="float: left; text-align: left; line-height: 150% "><BR>❑ Hospital admission<BR>❑ NPO<br>❑ IVF & correct electrolyte abnormalities<br>❑ Empiric IV antibiotics<ref name="Solomkin-2003">{{Cite journal | last1 = Solomkin | first1 = JS. | last2 = Mazuski | first2 = JE. | last3 = Baron | first3 = EJ. | last4 = Sawyer | first4 = RG. | last5 = Nathens | first5 = AB. | last6 = DiPiro | first6 = JT. | last7 = Buchman | first7 = T. | last8 = Dellinger | first8 = EP. | last9 = Jernigan | first9 = J. | title = Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. | journal = Clin Infect Dis | volume = 37 | issue = 8 | pages = 997-1005 | month = Oct | year = 2003 | doi = 10.1086/378702 | PMID = 14523762 }}</ref>
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| :❑ [[Ceftriaxone]] 1 g IV every 24 hours/2 g IV every 12 hours for CNS infections<br>'''+'''<br> [[Metronidazole]] 500 mg IV every 8 hours
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| '''or'''
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| :❑ [[Ciprofloxacin]] 400 mg IV every 12 hours<br> '''or'''<br> [[Levofloxacin]] 500 or 750 mg IV once daily<br> '''+'''<br> Metronidazole 500 mg IV every 8 hours<br>❑ Acute pain management
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| :❑ [[Ketorolac]] 30-60 mg IM/IV single dose
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| '''or'''
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| :❑ [[Opioids]] until cholecystectomy if ketorolac is contraindicated/pain not improving<br>
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| ❑ [[Cholecystitis overview#Severity Grading|Assess severity]]<ref name="Hirota-2007">{{Cite journal | last1 = Hirota | first1 = M. | last2 = Takada | first2 = T. | last3 = Kawarada | first3 = Y. | last4 = Nimura | first4 = Y. | last5 = Miura | first5 = F. | last6 = Hirata | first6 = K. | last7 = Mayumi | first7 = T. | last8 = Yoshida | first8 = M. | last9 = Strasberg | first9 = S. | title = Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. | journal = J Hepatobiliary Pancreat Surg | volume = 14 | issue = 1 | pages = 78-82 | month = | year = 2007 | doi = 10.1007/s00534-006-1159-4 | PMID = 17252300 }}</ref></div>|C02=Immediate biliary drainage}}
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| {{familytree | | |)|-|-|-|v|-|-|-|.| | | |,|-|^|-|.| | |}}
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| {{familytree | | D01 | | D02 | | D03 | | D04 | | D05 | |D01=Grade 1 (Mild)|D02=Grade 2 (Moderate)|D03=Grade 3 (Severe)|D04=Patient improves|D05=Patient does not improve}}
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| {{familytree | | |!| | | |!| | | |!| | | |!| | | |!| | |}}
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| {{familytree | | E01 | | E02 | | E03 | | E04 | | E05 | |E01=[[Cholecystectomy]] within 72 hours|E02=<div style="float: left; text-align: left; line-height: 150% ">'''W/o complications & non high risk surgical candidates:'''<br>Immediate cholecystectomy + blood C&S ± bile C&S<br>'''W/o complications & high risk surgical candidates:'''<br>Immediate biliary drainage + blood C&S ± bile C&S<br>'''W/ complications:'''<br>Emergency cholecystectomy + blood C&S ± bile C&S ± appropriate surgeries for [[Gallstone ileus#Treatment|gallstone ileus]] & [[Mirizzi's syndrome surgery|Mirizzi syndrome]]</div>|E03=Emergency biliary drainage + blood C&S ± bile C&S|E04=Urgent cholecystectomy|E05=[[Abdominal pain resident survival guide|Consider evaluation for alternate diagnosis of abdominal pain]]}}
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| {{familytree | | | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | | | | | | | F01 | | | | | | | | | |F01=Cholecystectomy after 3 months if GBS found during biliary drainage}}
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| {{familytree/end}}
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| '''CNS:''' Central nervous system; '''C&S:''' Culture & sensitivity; '''GBS:''' Gallbladder stone; '''IV:''' Intravenous; '''IVF:''' Intravenous fluids; '''NPO:''' Nil per oral; '''W/:''' With; '''W/O:''' Without
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| ====Chronic Cholecystitis====
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| {{familytree/start |summary=Cholecystitis}}
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| {{familytree | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | |A01='''Chronic cholecystitis'''}}
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| {{familytree | | | | | | | | | | | | | |,|-|-|^|-|-|.| | | | | | | | | |}}
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| {{familytree | | | | | | | | | | | | | B01 | | | | B02 | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Uncomplicated chronic cholecystitis:'''<br>
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| Elective cholecystectomy</div>|B02=<div style="float: left; text-align: left; line-height: 150% ">'''Complicated chronic cholecystitis:'''<br>
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| Appropriate management of complications <BR>❑ [[Cholecystitis|Acute on chronic cholecystitis]]<BR>❑ [[Gallbladder cancer|Gallbladder carcinoma]]<BR>❑ [[Gallstone ileus#Treatment|Gallstone ileus]]</div>}}
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| {{familytree/end}}
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| ==Do's==
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| *Antibiotics should be administered if infection is suspected on the basis of laboratory and clinical findings (>12,500 white cells/mm <sup>3</sup> 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.<ref name="Solomkin-2003">{{Cite journal | last1 = Solomkin | first1 = JS. | last2 = Mazuski | first2 = JE. | last3 = Baron | first3 = EJ. | last4 = Sawyer | first4 = RG. | last5 = Nathens | first5 = AB. | last6 = DiPiro | first6 = JT. | last7 = Buchman | first7 = T. | last8 = Dellinger | first8 = EP. | last9 = Jernigan | first9 = J. | title = Guidelines for the selection of anti-infective agents for complicated intra-abdominal infections. | journal = Clin Infect Dis | volume = 37 | issue = 8 | pages = 997-1005 | month = Oct | year = 2003 | doi = 10.1086/378702 | PMID = 14523762 }}</ref>
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| *Prophylactic antibiotics before surgery
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| **Should be administered in highrisk patients (age >60 years, presence of [[diabetes]], acute colic within 30 days of operation, [[jaundice]], [[acute cholecystitis]], or [[cholangitis]]) ([[SAGES system classification scheme|Level I, Grade B]]).
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| **Should be limited to a single preoperative dose given within 1 hour of skin incision ([[SAGES system classification scheme|Level II, Grade A]]).
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| *Early [[laparoscopic cholecystectomy]] is the preferred approach and should be done in patients with acute cholecystitis ([[SAGES system classification scheme|Level II, Grade B]]).
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| *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 ([[SAGES system classification scheme|Level II, Grade B]]).
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| *Time to discharge after surgery for patients with acute cholecystitis should be determined on an individual basis ([[SAGES system classification scheme|Level III, Grade A]]).
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| ==Dont's==
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| *Antibiotics are not required in low-risk patients undergoing laparoscopic cholecystectomy ([[SAGES system classification scheme|Level I, Grade A]]).
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| *Drains are not required after elective laparoscopic cholecystectomy, and their use may increase complication rates. ([[SAGES system classification scheme|Level I, Grade A]]).
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| ==References==
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| {{Reflist|2}}
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