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

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.
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 are algorithms depicting the diagnostic and treatment approach of acute and chronic 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.

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 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)

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

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.
• 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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