Acute Cholecystitis

Background

• Acute cholecystitis is acute inflammation of the gallbladder, most commonly associated with obstruction of the cystic duct by gallstones or biliary sludge.
• Acalculous cholecystitis is gallbladder inflammation without stones and is seen primarily in critically ill patients. It requires a high degree of clinical suspicion, is difficult to diagnose, and is associated with a high mortality rate.
• Risk factors include female gender, obesity, hormone replacement therapy, severe hypertriglyceridemia, sickle cell disease, obesity surgery, sudden and significant weight loss, and gallbladder carcinoma.
• Acute cholecystitis may result in complications if not identified and treated promptly. Common disease-related complications can include severe sepsis, gangrenous cholecystitis, and gallbladder perforation with resultant bile peritonitis.

Evaluation

• Suspect acute cholecystitis if signs of both local inflammation (Murphy sign or right upper quadrant mass, pain, or tenderness) and systemic inflammation (fever, elevated white blood cell count, or elevated C-reactive protein) are present.
• If suspected, confirm acute cholecystitis with imaging, using abdominal ultrasound in most cases (Strong recommendation).
• Consider computed tomography for atypical presentations to assess a wider differential diagnosis.
• Obtain blood tests to assess severity or comorbidities including a complete blood count, C-reactive protein, blood urea nitrogen, creatinine, electrolytes, bilirubin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and amylase (Strong recommendation).
• Classify severity as mild (most cases), moderate if signs of severe inflammation, or severe if there is organ dysfunction.

Management

• Initial management includes providing nothing by mouth, IV fluids, electrolyte correction, and analgesics (Strong recommendation).
• For mild-to-moderate community-acquired acute cholecystitis, consider antibiotic therapy with cefazolin, cefuroxime, or ceftriaxone (Weak recommendation).
• For severe or health care-associated acute cholecystitis, give broad-spectrum antibiotics such as metronidazole plus a beta-lactam (ciprofloxacin, levofloxacin, ceftazidime, or cefepime), or monotherapy with meropenem, imipenem-cilastatin, doripenem, or piperacillin-tazobactam. Add vancomycin if Enterococcus or health care associated (Strong recommendation).
• Consider discontinuing antibiotics within 24 hours after cholecystectomy in most cases (Weak recommendation), but continuing antibiotics following cholecystectomy may be appropriate if systemic signs of sepsis persists following surgery, or if the patient is immunocompromised.(Weak recommendation).
• Perform cholecystectomy within 72 hours in mild acute cholecystitis (Strong recommendation).
• Although rare, if patients develop severe sepsis secondary to cholecystitis, treatment becomes more urgent, either in the form of cholecystectomy for patients stable for surgery, or in the form of a cholecystostomy tube (gallbladder drainage) for patients who are not candidates for surgery.