Cholecystitis resident survival guide: Difference between revisions

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==Management==
==Management==
Shown below is an algorithm depicting the management of 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> 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>
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>
 
===Diagnostic Approach===
====Acute Cholecystitis====
{{familytree/start |summary=Cholecystitis}}
{{familytree/start |summary=Cholecystitis}}
{{familytree | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms'''<br>❑ Abdominal pain</div>}}
{{familytree | | | | | | | | A01 | | | | | | | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:'''<br>❑ Acute RUQ or epigastric pain<br>
{{familytree | | | | | | | | | |,|-|-|-|+|-|-|-|.| | | | | | | | | | | | | | | | | }}
:❑ Sharp, severe and steady
{{familytree | | | | | | | | | B01 | | B02 | | B03 |,| B04 | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">❑ Acute RUQ or epigastric pain<br>
:For >6 hours
❑ Sharp, severe and steady pain<br>
:Radiating to right shoulder blade
Pain for >6 hours<br>
:After food intake
Pain radiating to right shoulder blade<br>
:Aggravated by movements
Pain after food intake<br>
:Associated with
Pain aggravated by movements<br>
::❑ [[Nausea]] & [[vomiting]]
Pain associated with nausea & vomiting<br>
::[[Diaphoresis]]
Pain associated with diaphoresis<br>
::[[Fever]]
Pain associated with fever<br>
::[[Anorexia]]
Pain associated with anorexia<br>
::Mass in the RUQ
Pain associated with mass in the RUQ<br>
::❑ Sx suggestive of [[Sepsis history and symptoms|sepsis]]
Pain associated with Sx suggestive of [[Sepsis history and symptoms|sepsis]]<br>Pain associated with Sx suggestive of Mirizzi syndrome<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
::❑ Sx suggestive of [[Mirizzi's syndrome|common hepatic duct obstruction]]
:❑ RUQ pain with fever & jaundice</div></div><br>Pain associated with Sx suggestive of gallstone ileus<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:::❑ RUQ pain with fever & [[jaundice]]
:❑ Transient abdominal pain with nausea & vomiting
::❑ Sx suggestive of [[gallstone ileus]]
:❑ Hematemesis</div></div></div>|B02=<div style="float: left; text-align: left; line-height: 150% ">❑ Acute vague abdominal pain<br>❑ RUQ mass<br>❑ Jaundice<br>❑ Fever</div>|B03=<div style="float: left; text-align: left; line-height: 150% ">Recurrent biliary type abdominal pain<br>❑ Recurrent abdominal bloating<br>❑ Unstable stool with constipation/diarrhea<br>❑ Weight loss</div>|B04=<div style="float: left; text-align: left; line-height: 150% ">'''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>}}
:::❑ Transient abdominal pain with nausea & vomiting
{{familytree | | | | | | | | | |!| | | |!| | | |!| |!| |!| | | | | | | | | | |}}
:::❑ [[Hematemesis]]<br>
{{familytree | | | | | | | | | C01 |-| C02 | | C03 |'| C04 | | | | | | | | | | | | |C01=<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>|C02=Consider DDx of '''acute acalculous cholecystitis'''|C03=Consider DDx of '''chronic cholecystitis'''|C04=<div style="float: left; text-align: left; line-height: 150% ">'''Uncomplicated chronic cholecystitis:'''<br>
❑ Acute vague abdominal pain
Elective cholecystectomy<br>
:❑ Associated with
'''Complicated chronic cholecystitis:'''<br>
::❑ RUQ mass
Appropriate management of complications like [[Cholecystitis|acute on chronic cholecystitis]] or [[Gallbladder cancer|GB CA]] or [[Gallstone ileus#Treatment|gallstone ileus]]</div>}}
::❑ Jaundice
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | |}}
::❑ Fever</div>}}
{{familytree | | | | | | | | | D01 |,| D02 |-| D03 |-|-|-|-|-|-|.| | | | | | | | | | |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</div>|D02=No GBS/GB edema|D03=[[Abdominal pain resident survival guide|Consider evaluation for alternate diagnosis of abdominal pain]]}}
{{familytree | | | | | | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | | |!| |!| | | | | | | | | | | | | |!| | | | | | |}}
{{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>}}
{{familytree | | | | | | | | | F01 |+| F02 |-| F03 |-| F04 | | |!| | | | | | | | | | | |F01='''Order urgent transabdominal USG (TAUSG)'''|F02=GBS w/o GB edema/GB edema w/o GBS|F03=HIDA scan|F04=GB opacity visualized}}
{{familytree | | | | | | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | | | | |!| | | | | |!| | | |!| | | |!| | | | |}}
{{familytree | | | | | | | | C01 | | | | | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Probable diagnosis:'''<BR>❑ Acute calculous cholecystitis<BR>❑ Acute acalculous cholecystitis
{{familytree | | | | | | | | | | | |`| G01 | | G02 | | G03 | | |!| | | | | | | | | | |G01=GBS w/ GB edema|G02=GB opacity not visualized|G03=CT abdomen}}
----
{{familytree | | | | | | | | | | | | | |!| | | |!| | | |!| | | |!| | | | | |}}
'''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>}}
{{familytree | | | | | | | | | H01 |-|-|^|-|-|-|'| | | H02 | | |!| | | | | | | | |H01=<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<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
{{familytree | | | | | | | | |!| | | | | | | | |}}
{{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
----
'''Order urgent transabdominal USG (TAUSG)'''</div>}}
{{familytree | | |,|-|-|-|-|-|+|-|-|-|-|-|.| | |}}
{{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}}
{{familytree | | |!| | | | | |!| | | | | |!| | |}}
{{familytree | | |!| | | | | F01 | | | | F02 | |F01=HIDA scan|F02=[[Abdominal pain resident survival guide|Consider evaluation for alternate diagnosis of abdominal pain]]}}
{{familytree | | |!| | | |,|-|^|-|.| | | | | | |}}
{{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<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:❑ [[Murphy’s sign]]
:❑ [[Murphy’s sign]]
:❑ Pain or tenderness in RUQ
:❑ Pain or tenderness in RUQ
Line 68: Line 80:
:❑ Elevated CRP</div></div><br>❑ Imaging findings<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:❑ Elevated CRP</div></div><br>❑ Imaging findings<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:❑ [[Cholecystitis ultrasound#Calculous Cholecystitis|TAUSG]]
:❑ [[Cholecystitis ultrasound#Calculous Cholecystitis|TAUSG]]
:❑ [[Cholecystitis other diagnostic studies#Calculous Cholecystitis|HIDA scan]] </div></div></div>|H02=<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<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:❑ [[Cholecystitis other diagnostic studies#Calculous Cholecystitis|HIDA scan]] </div></div></div>|G02=GB opacity not visualized|G03=GB opacity visualized}}
{{familytree | | |!| | | | | | | |!| | | | | | | |}}
{{familytree | | |)|-|-| H01 | | H02 | | | | | | |H01=W/ significantly elevated total bilirubin, alkaline phosphatase, ALT, AST &/or GGT|H02=CT abdomen}}
{{familytree | | |!| | | |!| | | |!| | | | | | | |}}
{{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<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:❑ [[Cholecystitis ultrasound#Imaging Criteria for Acalculous Cholecystitis|TAUSG based]]
:❑ [[Cholecystitis ultrasound#Imaging Criteria for Acalculous Cholecystitis|TAUSG based]]
:❑ [[Cholecystitis other diagnostic studies#Imaging Criteria for Acalculous Cholecystitis|HIDA scan based]]
:❑ [[Cholecystitis other diagnostic studies#Imaging Criteria for Acalculous Cholecystitis|HIDA scan based]]
:❑ [[Cholecystitis CT#Imaging Criteria for Acalculous Cholecystitis|CT based criteria]]</div></div></div>}}
:❑ [[Cholecystitis CT#Imaging Criteria for Acalculous Cholecystitis|CT based criteria]]</div></div></div>}}
{{familytree | | | | | | | | | |)|-|-| I01 |-| I02 | | |!| | | |!| | | | | | | |I01=W/ significantly elevated total bilirubin, alkaline phosphatase, ALT, AST &/or GGT|I02=Consider evaluation for alternate diagnosis like [[choledocholithiasis]] & [[cholangitis]]}}
{{familytree | | | | | | | | | | |!| | | | | | | |}}
{{familytree | | | | | | | | | J01 | | | | | | | | | | J02 | | |!| | | | | | | |J01='''Acute calculous cholecystitis'''<br>w/ or w/o complications|J02=Suspect '''acute acalculous cholecystitis'''}}
{{familytree | | | | | | | | | | J01 | | | | | | |J01=Suspect '''acute acalculous cholecystitis'''}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | |!| | | |!| | | | | |}}
{{familytree/end}}
{{familytree | | | | | | | | | K01 | | | | | | | | | | K02 |-| K03 | | | | | | | | |K01=<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><div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
'''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
:❑ Ceftriaxone 1 g IV every 24 hours or 2 g IV every 12 hours for CNS infections + Metronidazole 500 mg IV every 8 hours
 
====Chronic Cholecystitis====
{{familytree/start |summary=Cholecystitis}}
{{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>}}
{{familytree | | | | | | | | |!| | | | | | | | |}}
{{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>}}
{{familytree | | | | | | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | C01 | | | | | | | |C01=<div style="float: left; text-align: left; line-height: 150% ">'''Probable diagnosis:'''<br>❑ Chronic cholecystitis
----
'''Differential diagnosis'''<BR>❑ [[Biliary colic]]<BR>❑ [[Cholangiocarcinoma]]<BR>❑ [[Choledocholithiasis]]<BR>❑ [[Cholelithiasis]]<BR>❑ [[Gallbladder cancer]]<BR>❑ Gallbladder mucocele<BR>❑ [[Peptic ulcer disease]]</div>}}
{{familytree | | | | | | | | |!| | | | | | | | |}}
{{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
----
'''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>}}
{{familytree | | | | | | | | |!| | | | | | | | |}}
{{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>}}
{{familytree | | | | | | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | F01 | | | | | | | |F01='''Suspect chronic cholecystitis'''}}
{{familytree/end}}
'''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
 
===Treatment Approach===
====Acute Cholecystitis====
{{familytree/start |summary=Cholecystitis}}
{{familytree | | | | | | | | | A01 | | | | | | | | | | | |A01='''Acute cholecystitis'''}}
{{familytree | | |,|-|-|-|-|-|-|^|-|-|-|-|-|-|.| | | | | |}}
{{familytree | | B01 | | | | | | | | | | | | B02 | | | | |B01='''Acute calculous cholecystitis'''<br>w/ or w/o complications|B02='''Acute acalculous cholecystitis'''}}
{{familytree | | |!| | | | | | | | | | | | | |!| | | | | |}}
{{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><div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:❑ [[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
'''or'''
'''or'''
:❑ Ciprofloxacin 400 mg IV every 12 hours/Levofloxacin 500 or 750 mg IV once daily + Metronidazole 500 mg IV every 8 hours</div></div><br>❑ Acute pain management<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:❑ [[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</div></div><br>❑ Acute pain management<div class="mw-collapsible-content"> <div class="mw-collapsible mw-collapsed">
:❑ Ketorolac 30-60 mg IM/IV single dose
:❑ [[Ketorolac]] 30-60 mg IM/IV single dose
'''or'''
'''or'''
:❑ Opioids until cholecystectomy if ketorolac is contraindicated/pain not improving</div></div><br>
:❑ [[Opioids]] until cholecystectomy if ketorolac is contraindicated/pain not improving</div></div><br>
❑ [[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>|K02=Immediate biliary drainage|K03=Patient does not improve}}
❑ [[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}}
{{familytree | | | | | | | | | |)|-|-|-|v|-|-|-|.| | | |!| | | | | | | | | }}
{{familytree | | |)|-|-|-|v|-|-|-|.| | | |,|-|^|-|.| | |}}
{{familytree | | | | | | | | | L01 | | L02 | | L03 | | L04 | | | | | | | | | | |L01=Grade 1 (Mild)|L02=Grade 2 (Moderate)|L03=Grade 3 (Severe)|L04=Patient improves}}
{{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}}
{{familytree | | | | | | | | | |!| | | |!| | | |!| | | |!| | | | | | |}}
{{familytree | | |!| | | |!| | | |!| | | |!| | | |!| | |}}
{{familytree | | | | | | | | | M01 | | M02 | | M03 | | M04 | | | | |M01=Cholecystectomy within 72 hours|M02=<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>|M03=Emergency biliary drainage + blood C&S ± bile C&S|M04=Urgent cholecystectomy}}
{{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]]}}
{{familytree | | | | | | | | | | | | | | | | | |!| | | | | | | | | | |}}
{{familytree | | | | | | | | | | |!| | | | | | | | |}}
{{familytree | | | | | | | | | | | | | | | | | N01 | | | | | | | | | | | |N01=Cholecystectomy after 3 months if GBS found during biliary drainage}}
{{familytree | | | | | | | | | | F01 | | | | | | | | | |F01=Cholecystectomy after 3 months if GBS found during biliary drainage}}
{{familytree/end}}
'''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
 
====Chronic Cholecystitis====
{{familytree/start |summary=Cholecystitis}}
{{familytree | | | | | | | | | | | | | | | | A01 | | | | | | | | | | | | | | | |A01='''Chronic cholecystitis'''}}
{{familytree | | | | | | | | | | | | | |,|-|-|^|-|-|.| | | | | | | | | |}}
{{familytree | | | | | | | | | | | | | B01 | | | | B02 | | | | | | | | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Uncomplicated chronic cholecystitis:'''<br>
Elective cholecystectomy</div>|B02=<div style="float: left; text-align: left; line-height: 150% ">'''Complicated chronic cholecystitis:'''<br>
Appropriate management of complications <BR>❑ [[Cholecystitis|Acute on chronic cholecystitis]]<BR>❑ [[Gallbladder cancer|Gallbladder carcinoma]]<BR>❑ [[Gallstone ileus#Treatment|Gallstone ileus]]</div>}}
{{familytree/end}}
{{familytree/end}}
<sup>†</sup>'''ALT:''' Alanine aminotransferase; '''AST:''' Aspartate aminotransferase; '''BMP:''' Basic metabolic profile; '''C&S:''' Culture & sensitivity; '''CA:''' Carcinoma; '''CBC:''' Complete blood count; '''CT:''' Computed tomography; '''DDx:''' Differential diagnosis; '''GB:''' Gallbladder; '''GBS:''' Gallbladder stone; '''GGT:''' Gamma-glutamyl transpeptidase; '''HIDA scan:''' Hepatobiliary iminodiacetic acid scan; '''IV:''' Intravenous; '''IVF:''' Intravenous fluids; '''NPO:''' Nil per oral; '''RUQ:''' Right upper quadrant; '''Sx:''' Symptom; '''W/:''' With; '''W/O:'''  Without


==Do's==
==Do's==

Revision as of 21:25, 10 February 2014

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

Definitions

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 is 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] Data from multiple studies is used for suspecting the diagnosis of acute acalculous cholecystitis.[5]
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.[6]

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

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),[8] the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES),[9] the Tokyo guidelines for management of cholecystitis,[10] and review of data from multiple studies on acalculous cholecystitis.[5]

Diagnostic Approach

Acute Cholecystitis

 
 
 
 
 
 
 
Characterize the symptoms:
❑ Acute RUQ or epigastric pain
❑ Sharp, severe and steady
❑ For >6 hours
❑ Radiating to right shoulder blade
❑ After food intake
❑ Aggravated by movements
❑ Associated with
Nausea & vomiting
Diaphoresis
Fever
Anorexia
❑ Mass in the RUQ
❑ Sx suggestive of sepsis
❑ Sx suggestive of common hepatic duct obstruction
❑ RUQ pain with fever & jaundice
❑ Sx suggestive of gallstone ileus
❑ Transient abdominal pain with nausea & vomiting
Hematemesis

❑ Acute vague abdominal pain

❑ Associated with
❑ RUQ mass
❑ Jaundice
❑ Fever
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
Febrile
❑ Jaundice
❑ Dehydrated
❑ Tachycardia
❑ RUQ mass
Abdominal guarding
Murphy's sign
❑ Abdominal crepitations
❑ Abdominal tenderness
❑ Reduced bowel sounds
❑ Increased bowel sounds
Abdominal distension
Signs of sepsis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Probable diagnosis:
❑ Acute calculous cholecystitis
❑ Acute acalculous cholecystitis
Differential diagnosis
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)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
GBS w/ GB edema
 
 
 
GBS w/o GB edema/GB edema w/o GBS
 
 
 
No GBS/GB edema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
HIDA scan
 
 
 
Consider evaluation for alternate diagnosis of abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic criteria:[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
 
GB opacity not visualized
 
GB opacity visualized
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
W/ significantly elevated total bilirubin, alkaline phosphatase, ALT, AST &/or GGT
 
CT abdomen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute calculous cholecystitis
w/ or w/o complications
 
Consider evaluation for alternate diagnosis like choledocholithiasis & cholangitis
 
Diagnostic criteria:[5]
❑ Acute abdominal pain
❑ Fever
❑ Leukocytosis
❑ Abnormal liver function tets
❑ Imaging based criteria
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspect acute acalculous cholecystitis
 
 
 
 
 
 

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

Chronic Cholecystitis

 
 
 
 
 
 
 
Characterize the symptoms:
❑ Recurrent biliary type abdominal pain w/ or w/o fever
❑ Recurrent abdominal bloating
❑ Unstable stool with constipation/diarrhea
❑ Weight loss
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
Febrile
Jaundice
Murphy's sign
❑ Nonspecific finding
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Probable diagnosis:
❑ Chronic cholecystitis
Differential diagnosis
Biliary colic
Cholangiocarcinoma
Choledocholithiasis
Cholelithiasis
Gallbladder cancer
❑ Gallbladder mucocele
Peptic ulcer disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:
❑ CBC
❑ BMP
❑ CRP
❑ Total bilirubin
❑ Direct bilirubin
❑ Albumin
❑ AST
❑ ALT
❑ Alkaline phosphatase
❑ GGT
❑ Amylase
❑ Lipase
Order imaging studies:
TAUSG
CT abdomen
HIDA scan
Cholecystokinin stimulated HIDA scan
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic criteria:
❑ Chronic biliary Sx
❑ Absence of other pain sources during CT
❑ Stone-free TAUSG
❑ Delayed GB isotope accumulation, irregular GB filling, or photopenic areas and septations during HIDA cholescintigraphy
❑ Low EF (<35%) in cholecystokinin stimulated HIDA scan
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Suspect chronic cholecystitis
 
 
 
 
 
 
 

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

Treatment Approach

Acute Cholecystitis

 
 
 
 
 
 
 
 
Acute cholecystitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute calculous cholecystitis
w/ or w/o complications
 
 
 
 
 
 
 
 
 
 
 
Acute acalculous cholecystitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Hospital admission
❑ NPO
❑ IVF & correct electrolyte abnormalities
❑ Empiric IV antibiotics[11]
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]
 
 
 
 
 
 
 
 
 
 
 
Immediate biliary drainage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Grade 1 (Mild)
 
Grade 2 (Moderate)
 
Grade 3 (Severe)
 
Patient improves
 
Patient does not improve
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cholecystectomy within 72 hours
 
W/o complications & non high risk surgical candidates:
Immediate cholecystectomy + blood C&S ± bile C&S
W/o complications & high risk surgical candidates:
Immediate biliary drainage + blood C&S ± bile C&S
W/ complications:
Emergency cholecystectomy + blood C&S ± bile C&S ± appropriate surgeries for gallstone ileus & Mirizzi syndrome
 
Emergency biliary drainage + blood C&S ± bile C&S
 
Urgent cholecystectomy
 
Consider evaluation for alternate diagnosis of abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cholecystectomy after 3 months if GBS found during biliary drainage
 
 
 
 
 
 
 
 
 

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

Chronic Cholecystitis

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Chronic cholecystitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Uncomplicated chronic cholecystitis:
Elective cholecystectomy
 
 
 
Complicated chronic cholecystitis:
Appropriate management of complications
Acute on chronic cholecystitis
Gallbladder carcinoma
Gallstone ileus
 
 
 
 
 
 
 
 

Do's

  • Antibiotics should be administered 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.[11]
  • Prophylactic antibiotics before surgery
  • 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).
  • Time to discharge after surgery for patients with acute cholecystitis should be determined on an individual basis (Level III, Grade A).

Dont's

  • Antibiotics are not required in low-risk patients undergoing laparoscopic cholecystectomy (Level I, Grade A).
  • Drains are not required after elective laparoscopic cholecystectomy, and their use 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. doi:10.1056/NEJMcp0800929. PMID 18579815. 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. doi:10.1007/s00534-006-1150-0. PMID 17252291.
  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. doi:10.1007/s00534-006-1159-4. PMID 17252300.
  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. doi:10.1016/j.cgh.2009.08.034. PMID 19747982. Unknown parameter |month= ignored (help)
  6. Zhou, D.; Guan, WB.; Wang, JD.; Zhang, Y.; Gong, W.; Quan, ZW. (2013). "A comparative study of clinicopathological features between chronic cholecystitis patients with and without Helicobacter pylori infection in gallbladder mucosa". PLoS One. 8 (7): e70265. doi:10.1371/journal.pone.0070265. PMID 23936177.
  7. 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. doi:10.1007/s00534-006-1152-y. PMID 17252293.
  8. Duncan, CB.; Riall, TS. (2012). "Evidence-based current surgical practice: calculous gallbladder disease". J Gastrointest Surg. 16 (11): 2011–25. doi:10.1007/s11605-012-2024-1. PMID 22986769. Unknown parameter |month= ignored (help)
  9. 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. doi:10.1007/s00464-010-1268-7. PMID 20706739. Unknown parameter |month= ignored (help)
  10. 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)
  11. 11.0 11.1 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. doi:10.1086/378702. PMID 14523762. Unknown parameter |month= ignored (help)


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