Cholecystitis management

Cholecystitis management

Definition

Cholecystitis is inflammation of the gallbladder that occurs most commonly because of an obstruction of the cystic duct by gallstones (stone impaction in cystic duct leads to inflammation behind obstruction causing gallbladder swelling and secondary infection of biliary fluid).

Acalculous cholecystitis occurs in critically ill patients. Gallbladder stasis and ischemia (without cholelithiasis) leads to necroinflammation.

Clinical presentation

• Right upper quadrant (RUQ)/epigastric pain radiating to right shoulder/back

• Nausea and vomiting

• Fever

• Signs of peritoneal irritation may be present

• Patients with acalculous cholecystitis may present with fever and sepsis alone

• RUQ tenderness

• Murphy’s sign

• Palpable gallbladder

• Jaundice

The absence of physical findings does not rule out the diagnosis of cholecystitis.

Investigations

• Full blood count (FBP)

• Liver function tests (LFT)

• Amylase

• Lipase

• Ultrasonography (RUQ ultrasound): high sensitivity and specificity for stones but requires specific signs of cholecystitis:

  • Gallbladder wall thickening >4 mm

  • Pericholecystic fluid

  • Sonographic Murphy’s sign

• Radiography

• Computed tomography (CT)

• Magnetic resonance imaging (MRI)

• Hepatobiliary scintigraphy (HIDA)

• Endoscopic retrograde cholangiopancreatography (ERCP)

Pharmacological treatment

In acute cholecystitis, the initial treatment includes bowel rest, IV hydration, and correction of electrolyte abnormalities.

• Paracetamol (PO) 1 g 8 hourly daily OR paracetamol (IV) 1 g 8 hourly daily (for analgesia)

  AND

• Metoclopramide (IV/PO) 10 mg 12 hourly daily (for intractable vomiting)

Antibiotic therapy (severe or complicated cases)

• Piperacillin + tazobactam FDC (IV) 4.5 g 6–8 hourly for 7–10 days

  OR

• Ceftriaxone (IV) 1–2 g 24 hourly for 7–10 days

  OR

• Ciprofloxacin (IV) 200–400 mg 12 hourly for 7–10 days

  AND

• Metronidazole (IV) 500 mg 8 hourly for 7–10 days

Outpatient treatment (uncomplicated cases)

• Ciprofloxacin (PO) 500 mg 12 hourly for 7 days

  AND

• Metronidazole (PO) 400 mg 12 hourly for 7 days

Note

• Laparoscopic cholecystectomy is the standard of care for surgical treatment of cholecystitis; others include ERCP.

• Endoscopic ultrasound-guided transmural cholecystostomy and endoscopic gallbladder drainage may be considered.