Acute cholecystitis resident survival guide

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.
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.

Causes

Life Threatening Causes

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

• Gangrenous cholecystitis

Common Causes

• Acalculous cholecystitis
• Calculous cholecystitis

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), 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: ❑ 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: ❑ 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: ❑ 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), 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 ❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ Empiric IV antibiotics ❑ 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

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

❑ Consider evaluation for alternate diagnosis of abdominal pain

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.
• 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

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