Acute cholecystitis

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

Key Recommendations

When a diagnosis of acute cholecystitis is suspected, medical treatment, including nothing by mouth, intravenous fluids, antibiotics, and analgesia, together with close monitoring of blood pressure, pulse, and urinary output, should be initiated, with a view to carrying out early laparoscopic cholecystectomy. Simultaneously, the grade of severity needs to be established. Appropriate treatment should be performed in accordance with the severity grade. Operative risk should also be evaluated based on the severity grade.

Cholecystectomy

Cholecystectomy is the definitive treatment, as gallbladder inflammation often persists despite medical therapy.[52] This can be performed by laparoscopy or laparotomy (i.e., open approach); due to a low complication rate and shortened hospital stay laparoscopic approach is recommended first-line but should be avoided in cases of septic shock or where there are contraindications to anesthesia.[36]

Cholecystectomy is carried out as soon as possible after the onset of cholecystitis unless the patient is critically ill with severe cholecystitis and is thought to have a high operative risk, or inflammation is thought to have been present for more than 7 days. This is because of the high risk of intraoperative difficulties, which include heavy hemorrhage and possibly liver failure.

There is some evidence that patient selection may be improved by restricting surgery to those with unambiguous findings of cholecystitis. In one noninferiority study of patients with symptomatic uncomplicated gallstones, a restrictive selection process (using a triage instrument based on the Rome criteria of biliary colic) was associated with fewer cholecystectomies than usual care (selection for cholecystectomy left to the discretion of the surgeon).[53] Of those patients who did not undergo surgery (303), 34% (102) subsequently received an alternative diagnosis. The primary outcome, pain at 12 months, was similar between patients randomized to restrictive selection or to usual care.

Early cholecystectomy in older patients

One systematic review of 592 patients ages ≥70 years found that early cholecystectomy is a feasible treatment in older patients, with perioperative morbidity of 24% and perioperative mortality of 3.5%.[54] Older patients should be carefully selected; perioperative complications and mortality may be attributable to comorbid conditions and/or reduced physiologic reserves rather than the surgical procedure.[54][55]

Laparoscopic cholecystectomy

The preferred surgical approach: early laparoscopic cholecystectomy (ELC, performed within 72 hours of symptom onset according to the 2018 Tokyo guidelines or within 7 days of hospital admission or 10 days of symptom onset according to the 2020 World Society of Emergency Surgery [WSES] guidelines) is safe and associated with less overall morbidity, shorter total hospital stay, and shorter duration of antibiotic therapy compared with delayed cholecystectomy (performed ≥6 weeks after the onset of symptoms), with no increased conversion rate to open cholecystectomy.[34][36][56][57][58][59] [ ] ELC is also associated with lower hospital costs, fewer work days lost, and greater patient satisfaction.[57][60][61][62][63][64]
Conversion to the open procedure may be required if there is significant inflammation, difficulty delineating the anatomy, or significant bleeding.[65][66] Conversion rates were assessed in one retrospective review of 493 patients with acute cholecystitis from 2010-2013. Severity classification according to the 2013 Tokyo guidelines was found to be the most powerful predictive factor for conversion.[67] Male sex, diabetes mellitus, and total bilirubin level were also found to be independent risk factors for conversion to open surgery.[67] The operating surgeon should be experienced in carrying out laparoscopic cholecystectomies, have access to intraoperative cholangiography should it be needed, and have a low threshold for conversion to open surgery if required.
Patients with Child-Turcotte-Pugh grade A or B liver cirrhosis who undergo laparoscopic cholecystectomy have fewer overall postoperative complications than those who undergo the open procedure.[68]

The placement of a prophylactic drain does not reduce complications associated with laparoscopic cholecystectomy in patients with acute cholecystitis.[69]

Open cholecystectomy

May be appropriate for patients with gallbladder mass, extensive upper abdominal surgery, suspicion of malignancy, septic shock, or late third trimester of pregnancy, although increasing evidence supports the safety of laparoscopic cholecystectomy at all stages of pregnancy.[65][66][70] It is also indicated if there is significant gallbladder inflammation, difficulty delineating the anatomy, significant bleeding, presence of adhesions, or laparoscopic cholecystectomy complications. [Figure caption and citation for the preceding image starts]: Operative photo showing acute cholecystitisFrom the collection of Dr Charles Bellows; used with permission [Citation ends].

Percutaneous cholecystostomy

The 2020 WSES guidelines recommend early laparoscopic cholecystectomy whenever possible, even in subgroups of patients who are considered fragile.[36] However, early gallbladder drainage (cholecystostomy) should be considered as an alternative option for the following patients:[36][71]

Failed medical management, or poor surgical candidates

Ages >70 years, diabetes, a distended gallbladder, persistently elevated WBC (>15,000 cells/microliter). The presence of these factors may predict the development of complications (e.g., gangrenous cholecystitis) or failure of conservative treatment.

Retrospective data suggest that clinical improvement can be expected in 80% of patients with acute cholecystitis within 5 days of placement.[72]

Contraindications include coagulopathy that cannot be corrected, massive ascites that cannot be drained, and suspicion for gangrenous or perforated cholecystitis.

Percutaneous cholecystostomy is a minimally invasive procedure most often performed in patients who have a high surgical risk, and occasionally in critically ill patients. During the procedure, the inflamed gallbladder is localized with sonography or fluoroscopy after the oral administration of contrast medium. Computed tomography-guided access may help if no sonographic window is found. A tube is then placed through the skin to drain or decompress the gallbladder.

Technical success of percutaneous cholecystostomy is high in experienced hands (95% to 100%), and complication rates are low. Complications include catheter dislodgment, vagal reaction, bile leakage and peritonitis, and hemorrhage.[73][74][75]

Outcomes

One systematic review failed to determine the role of percutaneous cholecystostomy in the clinical management of high-risk surgical patients with acute cholecystitis because of the limited number of randomized clinical trials (RCTs) and their small sample size.[76] One subsequent systematic review found that cholecystectomy is superior to percutaneous cholecystostomy with respect to mortality, length of hospital stay, and rate of readmission for biliary complaints in critically ill patients with acute cholecystitis.[77] However, all the studies included in this review were retrospective.[77]

In the first RCT to compare laparoscopic cholecystectomy with percutaneous cholecystostomy in high-risk surgical patients (n=142, with acute calculous cholecystitis), cholecystectomy was associated with significantly fewer major complications (12% vs. 65%) and reduced rates of reintervention.[78]

Complications of percutaneous cholecystostomy

An incomplete or poor response within the first 48 hours may indicate complications (e.g., tube dislodgement, gallbladder wall necrosis) or the wrong diagnosis.[7] Extrahepatic and transhepatic approaches to percutaneous cholecystostomy have been advocated.[79] A transhepatic route minimizes the risk of intraperitoneal bile leakage and inadvertent injury to the hepatic flexure of the colon.[73] A subhepatic or transperitoneal approach is more favorable if stone extraction is planned due to the need for tract dilation.[74]

Patient follow-up

Patients treated with cholecystostomy tube can be discharged with their tube in place after the inflammatory process has resolved clinically. These patients should subsequently undergo a cholangiogram through the cholecystostomy tube (6-8 weeks) to see whether the cystic duct is open. If the duct is open and the patient is a good surgical candidate, they should be referred for cholecystectomy. However, more than 50% of patients with acute cholecystitis may undergo percutaneous cholecystostomy as definite treatment without subsequent cholecystectomy.[74]

Management based on severity grade (Tokyo guidelines)

The 2018 Tokyo guideline outlines treatment strategies for patients based on their severity grade: mild, moderate, or severe.[34] The WSES takes a different approach, stratifying patients who are surgical candidates with common bile duct stones into low, moderate, or high risk and recommending intervention within 72 hours or at least within 7 days of hospital admission and within 10 days of onset of symptoms where appropriate.

This section outlines the Tokyo approach in more detail but it would be recommended to check local pathways and guidance.

Mild (grade I)

Defined as acute cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder; responds to initial medical treatment.[35]
Antibiotics are recommended if infection is suspected on the basis of laboratory and clinical findings.[80]
Empiric intravenous antibiotic therapy should be started before the infecting isolates are identified. Antibiotic choice largely depends on local susceptibility patterns.[80] Local susceptibility patterns vary geographically and over time. The likelihood of resistance of the organism will also vary by whether the infection was hospital- or community-acquired, although there may be resistant organisms in the community.[80]

Options include a suitable cephalosporin (e.g., ceftriaxone), a carbapenem (e.g., ertapenem), or a fluoroquinolone (e.g., ciprofloxacin, levofloxacin, moxifloxacin). Fluoroquinolones are only recommended if the susceptibility of cultured isolates is known or for patients with beta‐lactam allergies.[80]
- Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to: tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behavior.[81]
- Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics that are commonly recommended for the infection are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability). Consult your local guidelines and drug information source for more information on suitability, contraindications, and precautions.
The 2018 Tokyo guideline also recommends ampicillin/sulbactam, a penicillin with a beta-lactamase inhibitor, as an alternative option (if the resistance rate is <20%); however this is not recommended in North American guidelines due to widespread resistance.[80][82]
Anaerobic antibiotic cover (e.g., metronidazole, clindamycin) is warranted if a biliary‐enteric anastomosis is present and the patient is started on an empiric regimen that does not adequately cover Bacteroides species.[80]
Patients are observed and treated with antibiotics. However, supportive care alone may be sufficient preceding delayed elective cholecystectomy.[83]
Antibiotic therapy can be discontinued within 24 hours of cholecystectomy in grade I disease.[84] However, if perforation, emphysematous changes, or necrosis of the gallbladder are noted during cholecystectomy, antibiotic therapy duration of 4-7 days is recommended.[80] Intravenous antibiotics may be switched to a suitable oral antibiotic regimen once the patient can tolerate oral feeding.[80][85]
Medical treatment may be sufficient for patients with mild (grade I) disease, and urgent surgery may not be required if timely access to laparoscopic expertise is limited.[52] However, for most patients ELC should be considered the primary approach (within 1 week of onset of symptoms).[56][86]
Patients require adequate analgesia (e.g., acetaminophen and/or an opioid). Nonsteroidal anti-inflammatory drugs (NSAIDs) may benefit patients with biliary colic but must be used with caution particularly in patients with a likelihood of early surgery, due to increased risk of gastrointestinal bleeding.[29][87] In practice, NSAIDs are usually avoided in patients with established cholecystitis.
The Tokyo guidelines state that ELC is the preferred treatment.[34][88][89] ELC (within 72 hours of onset of symptoms) has a clear benefit compared with delayed cholecystectomy (>6 weeks after index admission) in terms of complication rate, cost, quality of life, and hospital stay.[57][60][61][62][63][64]
There is no advantage to delaying cholecystectomy for acute cholecystitis on the basis of outcomes.[90] Early surgery, even when performed in patients >72 hours from symptom onset, is safe and associated with less overall morbidity, shorter total hospital stay and duration of antibiotic therapy, and reduced cost compared with delayed cholecystectomy (performed ≥6 weeks after the onset of symptoms).[58][59] [ ]
Perioperative administration of antibiotic prophylaxis: one randomized study of patients with mild acute cholecystitis found no difference in postoperative infection rates between people receiving a single preoperative intravenous dose of antibiotic (cefazolin) and the group that received an additional 3 days of intravenous antibiotics (cefuroxime and metronidazole) postoperatively.[91] Postoperative antibiotic therapy is typically reserved for selected patients and may not be required for patients who received preoperative and intraoperative antibiotics.[92][93][94]
Percutaneous cholecystostomy should be considered if medical management fails and patients are poor surgical candidates. These patients should subsequently undergo a cholangiogram through the cholecystostomy tube (6-8 weeks) to see whether the cystic duct is open. If the duct is open and the patient is a good surgical candidate, they should be referred for cholecystectomy. Alternatively, endoscopic transpapillary gallbladder drainage or endoscopic ultrasound (EUS)-guided gallbladder drainage can be considered in some resource settings.[95][96][97] More recent systematic reviews and meta-analyses have shown EUS gallbladder drainage to be associated with better clinical outcomes than percutaneous cholecystostomy and endoscopic transpapillary gallbladder drainage in high-risk surgical patients.[95][98][99] The American Gastroenterological Association suggests the use of EUS gallbladder drainage in high-risk surgical patients with acute cholecystitis, removal of percutaneous cholecystostomy drains in patients who are not candidates for cholecystectomy by allowing internal drainage, and drainage of malignant biliary obstruction in select patients.[95] The American Society for Gastrointestinal Endoscopy also recommends EUS-guided gallbladder drainage for selected patients who are not candidates for cholecystectomy.[100] There is good evidence to show that this procedure is effective in treating acute cholecystitis, though it is a technically challenging procedure that should only be done in specialist centers by clinicians trained and experienced in using this procedure for gallbladder drainage.[99][101][102][103]

Moderate (grade II)

Defined as acute cholecystitis associated with any one of the following: elevated white blood cell count (>18,000/microliter), palpable tender mass in the right upper abdominal quadrant, duration of complaints >72 hours, and marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis).[35] Moderate-grade cholecystitis usually does not respond to the initial medical treatment.
When a diagnosis of acute cholecystitis is suspected, medical treatment, including nothing by mouth, intravenous fluids, antibiotics, and analgesia, together with close monitoring of blood pressure, pulse, and urinary output, should be initiated.
Antibiotics are required if infection is suspected on the basis of laboratory and clinical findings. Empiric intravenous antibiotic therapy should be started before the infecting isolates are identified. Antibiotic choice largely depends on local susceptibility patterns.[80] Local susceptibility patterns vary geographically and over time. The likelihood of resistance of the organism will also vary by whether the infection was hospital- or community-acquired, although there may be resistant organisms in the community.[80] Choice of antibiotic regimen follows the same principles as for grade I disease and is detailed in the section above. Antibiotic therapy can be discontinued within 24 hours after cholecystectomy is performed in grade II disease. However, if perforation, emphysematous changes, or necrosis of gallbladder are noted during cholecystectomy, antibiotic therapy duration of 4-7 days is recommended.[80] Intravenous antibiotics may be switched to a suitable oral antibiotic regimen once the patient can tolerate oral feeding.[80][85]
Patients who do not improve under conservative treatment are referred for either surgery or percutaneous cholecystostomy, usually within 1 week of onset of symptoms.[56][86] ELC could be indicated if advanced laparoscopic techniques and skills are available.[34]
In patients with moderately severe cholecystitis, where there is no organ dysfunction but there is extensive disease in the gallbladder (which can confer difficulty in safely carrying out a cholecystectomy), ELC or open cholecystectomy by a highly experienced surgeon is preferred. If operative conditions make anatomic identification difficult, ELC should be promptly terminated by conversion to open cholecystostomy. Interval cholecystectomy can then be performed in 6-8 weeks.[34] Limiting factors to emergency surgery include availability of surgical staff, theater space, and radiologic investigations. Percutaneous cholecystostomy should be considered for poor surgical candidates. These patients should subsequently undergo a cholangiogram through the cholecystostomy tube (6-8 weeks) to see whether the cystic duct is open.[35][36] If the duct is open and the patient is a good surgical candidate, they should be referred for cholecystectomy.

Severe (grade III)

Defined as organ dysfunction in at least any one of the following organs/systems: cardiovascular (hypotension requiring treatment with dopamine beyond a certain dose, or any dose of norepinephrine); central nervous system (decreased level of consciousness); respiratory (PaO₂/FiO₂ ratio <300); renal (oliguria, creatinine >2.0 mg/dL); hepatic (INR >1.5); hematologic (platelet count <100,000 cells/microliter); severe local inflammation.[35] Intensive supportive care is required to monitor and treat organ dysfunction. Appropriate organ support may include oxygen, noninvasive/invasive positive pressure ventilation, or use of vasopressors alongside usual initial medical management (e.g., intravenous fluids, correction of electrolyte disturbances, and analgesics).[34] Requires urgent management of severe local inflammation by percutaneous cholecystostomy followed, where indicated, by delayed elective cholecystectomy 2-3 months later, when the patient's general condition has improved.[34][89] Patients treated with cholecystostomy can be discharged with their tube in place after the inflammatory process has resolved clinically. These patients should subsequently undergo a cholangiogram through the cholecystostomy tube (6-8 weeks) to see whether the cystic duct is open. If the duct is open and the patient is a good surgical candidate, they should be referred for cholecystectomy.
Antibiotics are required if infection is suspected on the basis of laboratory and clinical findings. Empiric intravenous antibiotic therapy should be started before the infecting isolates are identified. Antibiotic choice largely depends on local susceptibility patterns. Local susceptibility patterns vary geographically and over time. The likelihood of resistance of the organism will also vary by whether the infection was hospital- or community-acquired, although there may be resistant organisms in the community.[80] Options include a penicillin with a beta-lactamase inhibitor (e.g., piperacillin/tazobactam), a suitable cephalosporin (e.g., cefepime), a carbapenem (e.g., ertapenem, meropenem), or a monobactam (e.g., aztreonam).[80]
Vancomycin is recommended as an adjunct to cover Enterococcus species in grade III infections. Linezolid or daptomycin are recommended in place of vancomycin if vancomycin‐resistant Enterococcus is known to be colonizing the patient, if previous treatment included vancomycin, and/or if the organism is common in the community.[80]
Anaerobic antibiotic cover (e.g., metronidazole, clindamycin) is warranted if a biliary‐enteric anastomosis is present and the patient is started on an empiric regimen that does not adequately cover Bacteroides species.[80]
Once the source of infection is controlled, the recommended duration of antibiotic treatment is 4-7 days. If bacteremia with gram‐positive cocci (e.g., Enterococcus species, Streptococcus species) is present, a duration of at least 2 weeks is recommended.[80] If residual stones or obstruction of the bile tract are present, treatment should be continued until these anatomic problems are resolved. If liver abscess is present, treatment should be continued until clinical, biochemic, and radiologic follow‐up demonstrates complete resolution of the abscess.[80] Intravenous antibiotics may be switched to a suitable oral antibiotic regimen once the patient can tolerate oral feeding.[80][85]

Central venous catheter insertion: animated demonstration

Ultrasound-guided insertion of a non-tunnelled central venous catheter (CVC) into the right internal jugular vein using the Seldinger insertion technique.

Peripheral intravascular catheter: animated demonstration

How to insert a peripheral intravascular catheter into the dorsum of the hand.

Practical suturing techniques: animated demonstrations

Demonstrates interrupted sutures, vertical mattress sutures, horizontal mattress sutures, continuous subcuticular sutures, and continuous sutures.

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