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]

Definitions

Terms	Definitions
Cholecystitis	Cholecystitis is an inflammatory disease of the gallbladder.
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 is 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. Data from multiple studies is used for suspecting the diagnosis of acute acalculous cholecystitis.
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.

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

Shown below is a diagram depicting the management of cholecystitis according to the Society for Surgery of the Alimentary Tract (SSAT), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), Tokyo guidelines for management of cholecystitis, and review of data from multiple studies on acalculous cholecystitis.

Characterize the symptoms ❑ Abdominal pain

❑ Acute RUQ or epigastric pain ❑ Sharp, severe and steady pain ❑ Pain for >6 hours ❑ Pain radiating to right shoulder blade ❑ Pain after food intake ❑ Pain aggravated by movements ❑ Pain associated with nausea & vomiting ❑ Pain associated with diaphoresis ❑ Pain associated with fever ❑ Pain associated with anorexia ❑ Pain associated with mass in the RUQ ❑ Pain associated with Sx suggestive of sepsis ❑ Pain associated with Sx suggestive of Mirizzi syndrome ❑ RUQ pain with fever & jaundice ❑ Pain associated with Sx suggestive of gallstone ileus ❑ Transient abdominal pain with nausea & vomiting ❑ Hematemesis

❑ Acute vague abdominal pain ❑ RUQ mass ❑ Jaundice ❑ Fever

❑ Recurrent biliary type abdominal pain ❑ Recurrent abdominal bloating ❑ Unstable stool with constipation/diarrhea ❑ Weight loss

Imaging studies: TAUSG CT abdomen HIDA scan Cholecystokinin stimulated HIDA scan

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

Consider DDx of acute acalculous cholecystitis

Consider DDx of chronic cholecystitis

Uncomplicated chronic cholecystitis: Elective cholecystectomy Complicated chronic cholecystitis: Appropriate management of complications like acute on chronic cholecystitis or GB CA or gallstone ileus

Order laboratory tests: ❑ CBC ❑ BMP ❑ CRP ❑ Total bilirubin ❑ Direct bilirubin ❑ Albumin ❑ AST ❑ ALT ❑ Alkaline phosphatase ❑ GGT ❑ Amylase ❑ Lipase

No GBS/GB edema

Consider evaluation for alternate diagnosis of abdominal pain

Order urgent transabdominal USG (TAUSG)

GBS w/o GB edema/GB edema w/o GBS

HIDA scan

GB opacity visualized

GBS w/ GB edema

GB opacity not visualized

CT abdomen

Diagnostic criteria: ❑ 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

Diagnostic criteria: ❑ Acute abdominal pain ❑ Fever ❑ Leukocytosis ❑ Abnormal liver function tets ❑ Imaging based criteria ❑ TAUSG based ❑ HIDA scan based ❑ CT based criteria

W/ significantly elevated total bilirubin, alkaline phosphatase, ALT, AST &/or GGT

Consider evaluation for alternate diagnosis like choledocholithiasis & cholangitis

Acute calculous cholecystitis w/ or w/o complications

Suspect acute acalculous cholecystitis

❑ Hospital admission ❑ NPO ❑ IVF & correct electrolyte abnormalities ❑ Empiric IV antibiotics ❑ Ceftriaxone 1 g IV every 24 hours or 2 g IV every 12 hours for CNS infections + Metronidazole 500 mg IV every 8 hours or ❑ Ciprofloxacin 400 mg IV every 12 hours/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

Immediate biliary drainage

Patient does not improve

Grade 1 (Mild)

Grade 2 (Moderate)

Grade 3 (Severe)

Patient improves

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

Cholecystectomy after 3 months if GBS found during biliary drainage

^†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

• 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.
• Prophylactic antibiotics before surgery
  • Should be administered in highrisk patients (age >60 years, presence of diabetes, acute colic within 30 days of operation, jaundice, acute cholecystitis, or cholangitis) (Level I, Grade B).
  • Should be limited 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).
• 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

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