Cholecystitis resident survival guide

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

Cholecystitis

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.[1][2]
Acute calculous cholecystitis Acute calculous cholecystitis is an acute inflammatory disease of the gallbladder in the presence of cholelithiasis.[1]
Acute acalculous cholecystitis Acute acalculous cholecystitis is an acute necroinflammatory disease of the gallbladder in the absence of cholelithiasis and has a multifactorial pathogenesis.[3]
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.[4]

Acute Calculous Cholecystitis Diagnostic Criteria

The Tokyo guidelines is used in the diagnosis of acute calculous cholecystitis.[5][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

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. ↑ 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)
  4. ↑ 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.
  5. ↑ 5.0 5.1 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.
  6. ↑ 6.0 6.1 6.2 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.
  7. ↑ 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)


Template:WikiDoc Sources

 
 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms
❑ Abdominal pain
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
❑ Febrile
❑ Tachycardia
❑ Dehydrated
❑ Abdominal guarding
❑ Murphy's sign
❑ Abdominal creps
❑ Abdominal tenderness
❑ Reduced bowel sounds
❑ Increased bowel sounds
❑ Abdominal distension
❑ Signs of sepsis
 
Consider DDx of acute acalculous cholecystitis
 
Consider DDx of chronic cholecystitis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order laboratory tests:
❑ CBC
❑ BMP
❑ 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 visualized
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
GBS w/ GB edema
 
GB not visualized
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic criteria:[5][6]
❑ Local symptoms & signs
❑ Murphy’s sign
❑ Pain or tenderness in RUQ
❑ Mass in RUQ

❑ Systemic signs
❑ Fever
❑ Leukocytosis
❑ Elevated CRP

❑ Imaging findings
❑ TAUSG confirmatory finding of GBS & GB edema
❑ HIDA scan confirmatory finding of GBS & GB edema
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑ Hospital admission
❑ NPO
❑ IVF & correct electrolyte abnormalities
❑ Empiric IV antibiotics[7]
❑ 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
❑ Opioids until cholecystectomy if ketorolac is contraindicated/pain not improving
❑ Assess severity[6]
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Grade 1 (Mild)
 
 
Grade 2 (Moderate)
 
 
Grade 3 (Severe)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Laparoscopic 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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cholecystectomy after 3 months if GBS found during biliary drainage
 
 
 
 
 
 
 
 
 
 
 
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