Acute cholecystitis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

associated organ dysfunction (severe; Tokyo guideline grade III)

1st line – intensive care admission

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1st line –

intensive care admission

In patients with severe acute cholecystitis (grade III according to the Tokyo guideline; see Assessing severity in Diagnosis recommendations for guidance on how to define grade of cholecystitis):[52]

Transfer the patient to the intensive care unit to monitor and treat the organ dysfunction.
Determine the degree of organ dysfunction and attempt to normalise function through organ support.
Consider urgent/early biliary drainage if it is not possible to control the gallbladder inflammation.

Oxygen therapy in your patient with asthma

Measure resting oxygen saturation in all acutely unwell patients.[92]

If your patient’s asthma is stable, follow guideline recommendations for oxygen saturation target for the presenting acute condition.
If the acute presenting condition triggers an acute exacerbation of your patient’s asthma, the Global Initiative for Asthma recommends controlled oxygen to maintain saturations between 93% and 95%.[93]
Be aware that pulse oximetry may overestimate oxygen saturation in patients with darker skin tones.[93]
Hypercapnia in asthma is a near fatal sign showing a patient is tiring and needs ventilatory support.[94] Intensive care support is needed immediately.[94]

Oxygen therapy in your patient with COPD

Measure resting oxygen saturations and be aware of additional factors to consider when prescribing oxygen therapy in a patient with COPD who is hypoxaemic.

Any patient with COPD requiring oxygen supplementation needs an arterial blood gas (ABG) measurement.[95]
Re-check ABG after 30 to 60 minutes in all patients.[95]

If a patient with comorbid COPD is critically ill (e.g., shock, sepsis, major head injury, status epilepticus, anaphylaxis, major trauma) and needs high levels of oxygen:

The British Thoracic Society (BTS) recommends an initial target oxygen saturation in line with the recommendation for patients without COPD.[95] Evidence suggests that targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[96][97]
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the ABG results.[95]

If a patient with comorbid COPD is acutely but not critically ill and is at risk of hypercapnic failure (including any patient with moderate or severe COPD, particularly if on long-term oxygen therapy, or with an alert card, or with a previous history of hypercapnic respiratory failure):[95]

Use an initial target oxygen saturation of 88% to 92%
Check ABG and recheck after 30 to 60 minutes.

If a patient with comorbid COPD is acutely but not critically ill and is NOT at risk of hypercapnic respiratory failure (e.g., stable, mild COPD with minimal symptoms):

Use an initial target oxygen saturation as recommended by guidelines for the presenting acute condition
- Evidence suggests that for most acutely ill patients, targeting an upper oxygen saturation level of 96% may be preferred compared with a higher level.[96][97]
Measure ABG as soon as possible[95]
Subsequently, you may need to adjust to controlled oxygen therapy with a target oxygen saturation range of 88% to 92% depending on the ABG results.[95]

If your patient is suitable for full escalation of care, refer for consideration of ventilation support if the patient is:

Severely hypoxaemic (PaO₂ <7.3 kPa [<54.8 mmHg]) despite oxygen therapy (based on expert opinion)
Hypercapnic (PaCO₂ >6 kPa [>45 mmHg]) with respiratory acidosis (pH <7.35)[95]
AND/OR
Exhibiting changes in mental status (confusion, coma).

Plus – analgesia

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Plus –

analgesia

Treatment recommended for ALL patients in selected patient group

Pain is the predominant symptom. Ensure it is treated promptly and effectively.[52]

Failure to control pain can compromise breathing and contribute to haemodynamic instability.
Use a pain score to monitor the response to analgesia and adjust the dose and/or type of analgesic medication in line with local pain management protocols.

Use paracetamol or a non-steroidal anti-inflammatory drug such as diclofenac or indometacin initially.[27][58] Move onto opioid analgesia (e.g., morphine) if required.[10]

Assess pain regularly using a suitable pain scale

Assess pain regularly using a pain scale suitable for the person's age and cognitive function.[98][99][100] Be aware that both pain and polypharmacy can be a trigger for delirium in your older patient with frailty.[101]

It may be especially challenging to evaluate the presence and degree of pain in a patient with cognitive impairment (e.g., due to dementia), or in a patient with impaired communication for any other reason (e.g., due to post-stroke aphasia).[102]
Follow local protocols, using a suitable pain scale for your patient. The British Geriatrics Society recommends the following:[100]
- For patients who are cognitively intact, use self-reporting with validated tools such as the 0-10 scale (Numeric Rating Scale) or the Faces Pain Scale[103][104]
- For patients who are cognitively impaired, attempt to use self-report and change from baseline, review of painful conditions, evaluation of pain behaviours (validated tools include PAINAD, PACSLAC-II, Abbey Pain Scale), carer report, and, if necessary, empirical analgesic trial.[105][106][107]

Analgesia in your patient with chronic kidney disease, heart failure, or asthma

Take your patient’s comorbidities into account when choosing the most appropriate analgesia and dosing regimen.

Chronic kidney disease (CKD)

It is extremely important to adjust the dose of opioids in your patient with reduced kidney function. Some sources recommend avoiding morphine, codeine, and tramadol altogether in some patients depending on their kidney function.[108]
- Active metabolites of several opioids including morphine can accumulate if the kidney cannot excrete them.[108]
- Opioids that have extensive hepatic metabolism, such as hydromorphone, may be preferable.[108]
- Shorter-acting opioids that are renally excreted, such as oxycodone, may be preferred, but should be used with caution as they can still accumulate in people who have impaired kidney function.[109]
Avoid non-steroidal anti-inflammatory drugs (NSAIDs) in your patient with CKD.[110]

Heart failure

Avoid NSAIDs in your patient with heart failure, as they increase the risk of worsening heart failure and hospitalisation with heart failure.[111]

Asthma

NSAIDs can worsen symptoms in some patients with asthma, so check if your patient has a known sensitivity.[93]

Primary options

paracetamol: oral: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; intravenous (<51 kg body weight): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; intravenous (≥51 kg body weight): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

paracetamol : oral: 500-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; intravenous (<51 kg body weight): 15 mg/kg intravenously every 4-6 hours when required, maximum 60 mg/kg/day; intravenous (≥51 kg body weight): 1000 mg intravenously every 4-6 hours when required, maximum 4000 mg/day (3000 mg/day if risk factors for hepatotoxicity)

diclofenac potassium: 75-150 mg/day orally (immediate-release) given in 2-3 divided doses when required

diclofenac potassium : 75-150 mg/day orally (immediate-release) given in 2-3 divided doses when required

diclofenac potassium: 75-150 mg/day orally (immediate-release) given in 2-3 divided doses when required

diclofenac sodium: 75-150 mg/day rectally given in divided doses when required; 75 mg intramuscularly once or twice daily when required for a maximum of 2 days

diclofenac sodium : 75-150 mg/day rectally given in divided doses when required; 75 mg intramuscularly once or twice daily when required for a maximum of 2 days

diclofenac sodium: 75-150 mg/day rectally given in divided doses when required; 75 mg intramuscularly once or twice daily when required for a maximum of 2 days

indometacin: 50-200 mg/day orally (immediate-release) given in 2-3 divided doses when required; 100 mg rectally twice daily when required

indometacin : 50-200 mg/day orally (immediate-release) given in 2-3 divided doses when required; 100 mg rectally twice daily when required

indometacin: 50-200 mg/day orally (immediate-release) given in 2-3 divided doses when required; 100 mg rectally twice daily when required

Secondary options

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

morphine sulfate : 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

morphine sulfate: 5-10 mg orally (immediate-release)/subcutaneously/intravenously/intramuscularly every 4 hours initially, adjust dose according to response

These drug options and doses relate to a patient with no comorbidities.