Download Acute Cholecystitis

Survey
yes no Was this document useful for you?
   Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Document related concepts

Dental emergency wikipedia, lookup

Transcript
Acute Cholecystitis
View online at http://pier.acponline.org/physicians/diseases/d642/d642.html
Module Updated:
CME Expiration:
2013-02-20
2016-02-20
Author
Badri Man Shrestha, MS, MPhil, MD, FRCS
Table of Contents
1. Prevention .........................................................................................................................2
2. Diagnosis ..........................................................................................................................4
3. Consultation ......................................................................................................................8
4. Hospitalization ...................................................................................................................11
5. Therapy ............................................................................................................................12
6. Patient Education ...............................................................................................................16
7. Follow-up ..........................................................................................................................17
References ............................................................................................................................19
Glossary................................................................................................................................23
Tables...................................................................................................................................25
Figures .................................................................................................................................30
Quality Ratings: The preponderance of data supporting guidance statements are derived from:
level 1 studies, which meet all of the evidence criteria for that study type;
level 2 studies, which meet at least one of the evidence criteria for that study type; or
level 3 studies, which meet none of the evidence criteria for that study type or are derived from expert opinion, commentary, or consensus.
Study types and criteria are defined at http://smartmedicine.acponline.org/criteria.html
Disclaimer: The information included herein should never be used as a substitute for clinical judgement and does not represent an official position of
the American College of Physicians. Because all PIER modules are updated regularly, printed web pages or PDFs may rapidly become obsolete.
Therefore, PIER users should compare the module updated date on the offical web site with any printout to ensure that the information is the most
current available.
CME Statement: The American College of Physicians is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide
continuing education for physicians. The American College of Physicians designates this enduring material for a maximum of 1 AMA PRA Category 1
CreditTM. Physicians should claim only credit commensurate with the extent of their participation in the activity. Purpose: This activity has been
developed for internists to facilitate the highest quality professional work in clinical applications, teaching, consultation, or research. Upon completion
of the CME activity, participants should be able to demonstrate an increase in the skills and knowledge required to maintain competence, strengthen
their habits of critical inquiry and balanced judgement, and to contribute to better patient care. Disclosures: Badri Man Shrestha, MS, MPhil, MD,
FRCS, current author of this module, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care
related organizations. Deborah Korenstein, MD, FACP, Co-Editor, PIER, has no financial relationships with pharmaceutical companies, biomedical
device manufacturers, or health-care related organizations. Richard B. Lynn, MD, FACP, Co-Editor, PIER, has no financial relationships with
pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Acute Cholecystitis
Top
1. Prevention
Consider medical therapy and prophylactic cholecystectomy in
patients with symptomatic gallstones.
1.1 Consider UDCA to dissolve symptomatic cholesterol gallstones.
Recommendations
• Consider prescribing oral UDCA, 8 to 12 mg/kg·d.
Evidence
• In a meta-analysis of trials published from 1966 to 1992 comprising 1949 patients, complete
dissolution was achieved in 18.2% of patients with CDCA, 37.3% with UDCA, and 62.8% with
combination therapy (1).
• A double-blind, randomized, controlled study showed up to 55% partial dissolution and up to 29%
complete dissolution of radiolucent gallstones with UDCA. Dissolution was most effective in stones
<5 mm in diameter (2).
• A randomized, double-blind study showed that in patients treated with UDCA, there was a
significant reduction in biliary cholesterol concentration, formation of cholesterol crystals, and bile
viscosity (3).
• A 2008 meta-analysis of five randomized, controlled trials including 521 patients showed significant
reduction of gallstone formation after bariatric surgery (RR, 0.43 [CI, 0.22 to 0.83]), with 8.8% of
those taking UDCA developing gallstones compared with 27.7% of those taking placebo (P=0.01)
(4).
• In a prospective study of 1059 patients who had laparoscopic cholecystectomy for symptomatic
gallstones, risk factors for developing acute cholecystitis were analyzed. Age older than 60 years,
male sex, the presence of cardiovascular disease, the presence of diabetes mellitus, and a history
of cerebrovascular accident (ischemic stroke or cerebral hemorrhage) were identified as
independent risk factors for acute cholecystitis after multivariate analysis. Acute cholecystitis was
associated with greater operative difficulty and more postoperative morbidity than chronic
cholecystitis. Therefore, an early cholecystectomy was recommended for the patients with risk
factors for acute cholecystitis (5).
Rationale
• UDCA can dissolve gallstones, decrease cholesterol crystal formation, and reduce the bile
saturation index.
Comments
• Patients must have a functioning gallbladder, and gallstones must be radiolucent in order to use
UDCA. Gallstones optimally should be <5 mm in diameter.
• Significant diarrhea will develop in 5% to 10% of patients taking UDCA.
• The most definitive preventive strategy for cholecystitis is cholecystectomy. Because of suboptimal
response rates and prolonged time needed for dissolution, medical therapy should be reserved for
patients unable to have surgery. A study comprising 177 patients concluded that UDCA does not
reduce biliary symptoms in highly symptomatic patients and that early cholecystectomy is
warranted in patients with symptomatic gallstones (6).
1.2 Consider diclofenac in patients with biliary colic.
Recommendations
• Consider administering diclofenac, 75 mg, intramuscularly in a single injection.
Evidence
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 2 of 32
Acute Cholecystitis
• A 2008 systematic review and meta-analysis that included seven randomized, controlled trials
(n=349 patients) comparing the efficacy of NSAIDs with other analgesic agents in the treatment of
biliary colic showed NSAIDs to be the analgesics of choice for biliary colic in limiting the progression
of colic to acute cholecystitis (7).
• A randomized, double-blind study of diclofenac showed satisfactory pain relief and decrease in
progression to acute cholecystitis. Four of 27 patients treated with diclofenac developed acute
cholecystitis compared with 11 of 26 placebo patients (P=0.04) (8).
• A randomized, double-blind study of diclofenac vs. hyoscine for acute biliary colic showed faster
and more effective pain relief in the diclofenac arm. A smaller percentage of patients in the
diclofenac group (16.7%) progressed to acute cholecystitis compared with the hyoscine group
(52.8%) (9).
Rationale
• Diclofenac provides pain relief in biliary colic and decreases the risk for acute cholecystitis.
1.3 Consider cholecystectomy for symptomatic gallstones.
Recommendations
• Consider laparoscopic cholecystectomy for patients with symptomatic gallstones.
Evidence
• A randomized, prospective study showed that in patients with biliary colic, 38% per year had
recurrent biliary pain and 2% per year required cholecystectomy for significant biliary symptoms
(10).
• Based on simulation modeling, prophylactic cholecystectomy may decrease mortality more than
conservative management in patients with symptomatic gallstones (11).
• There are no randomized trials comparing cholecystectomy vs. no cholecystectomy in patients with
silent gallstones. Further evaluation of observational studies, which measure such outcomes as
obstructive jaundice, gallstone-associated pancreatitis, and/or gallbladder cancer for sufficient
duration of follow-up, is necessary before randomized trials are designed to evaluate whether
cholecystectomy or no cholecystectomy is better for asymptomatic gallstones (12).
• The need for cholecystectomy was demonstrated in a study comparing outcomes in nongangrenous (n=174) vs. gangrenous cholecystitis (n=106). Mortality was significantly higher in the
latter group (0% vs. 4%; P=0.017). The risk factors associated with gangrenous cholecystitis
included older age (69 years vs. 57 years; P=0.001) and diabetes (19% vs. 10%; P=0.049). There
was no overall difference in complication rates between the non-gangrenous and gangrenous
cholecystitis groups (22% vs. 14%; P=0.102) when treated in a specialized unit (13).
Rationale
• A large percentage of patients with symptomatic gallstones will have recurrent symptoms and may
develop more serious complications.
Comments
• Surgical removal of the gallbladder and gallstones is the definitive therapy for preventing acute
cholecystitis.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 3 of 32
Acute Cholecystitis
Top
2. Diagnosis
Base the diagnosis of acute cholecystitis on the history, physical
exam, laboratory data, and radiologic studies.
2.1 Obtain patient history for features suggestive of acute cholecystitis.
Recommendations
• Ask about:
Details of pattern, duration, location, and radiation of pain
Related symptoms, such as fever, chills, nausea, or vomiting
Dark urine
Previous biliary colic
Patient's age
Presence of diabetes
• Note that the typical pain is mid-epigastric, progressing to right upper quadrant. Pain may also
radiate to right scapula, right shoulder, back, or lower abdomen.
Evidence
• A retrospective study showed that 73.5% of patients with acute cholecystitis had pain persisting
less than 24 hours, 54% had right upper quadrant pain, and 34% had mid-epigastric pain (14).
• A prospective study showed that 32.2% of patients with acute cholecystitis had fever, and 75%
had previous episodes of biliary colic (15).
• A retrospective study showed that in acute acalculous cholecystitis, advanced age was associated
with the presence of severe gallbladder complications (16).
• A retrospective study showed that a history of diabetes was significantly associated with the
development of gangrenous cholecystitis (17).
Rationale
• The history of acute cholecystitis often includes previous episodes of biliary colic, mid-epigastric
visceral pain radiating to the right upper quadrant, parietal pain, fever, chills, nausea, and
vomiting.
• Advanced age may correlate with the development of complications in acute cholecystitis.
• Diabetes may play a role in the development of complications in acute cholecystitis.
Comments
• In elderly patients (especially those with diabetes) with leukocytosis and acute cholecystitis,
consider early surgical evaluation owing to the increased risk for developing gallbladder
complications (16).
2.2 Perform physical exam for features suggestive of acute cholecystitis.
Recommendations
• Look for:
Abdominal tenderness
Murphy's sign (palpation of the right upper quadrant causing pain and arrest of inspiration)
Right upper quadrant mass
Fever
Jaundice
Peritoneal signs
Signs of hemodynamic instability
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 4 of 32
Acute Cholecystitis
Evidence
• A retrospective study showed that a positive Murphy's sign had a sensitivity of 97.2% and was
highly predictive (93.3%) of a positive hepatobiliary scintigraphic scan in the diagnosis of acute
cholecystitis (14).
• A retrospective study showed that 85% of patients with acute cholecystitis had right upper
quadrant tenderness, and 40% had tenderness elicited in other regions (18).
• A retrospective study showed that 23% of patients with acute cholecystitis had a palpable
gallbladder (19).
Rationale
• Classic findings on the exam of acute cholecystitis include right upper quadrant or mid-epigastric
tenderness with Murphy's sign.
• A right upper quadrant mass (palpable gallbladder) may be present.
• Peritoneal signs imply a perforated viscus.
Comments
• Peritoneal signs require immediate surgical evaluation.
2.3 Recognize the clinical setting of acute acalculous cholecystitis.
Recommendations
• Consider the diagnosis of acute acalculous cholecystitis in critically ill patients.
• Understand that the classic signs and/or symptoms of acute cholecystitis may be absent in
acalculous disease.
Evidence
• A retrospective study showed that 14% of all cases of acute cholecystitis were acalculous; 63% of
the patients had had surgery, 52% were in the ICU, 37% were on a ventilator, 33% were
hypotensive, 33% were fasting, and 18% were on TPN (20).
• A retrospective study showed that only 66.7% of patients with acute acalculous cholecystitis had
right upper quadrant pain (21).
Rationale
• Five percent to 15% of cases of acute cholecystitis are acalculous.
• Acute acalculous cholecystitis generally occurs in critically ill, septic patients.
• The classic findings of right upper quadrant pain, Murphy's sign, and fever may be absent in
intubated, unresponsive patients.
2.4 Use laboratory data to establish the diagnosis.
Recommendations
•
•
•
•
Look for evidence of leukocytosis.
Evaluate LFTs.
Use laboratory data to exclude other diseases.
See table Laboratory and Other Studies for Acute Cholecystitis.
Evidence
• A prospective study showed that 41% of patients with acute cholecystitis had elevated bilirubin
levels, 26% had elevated alkaline phosphatase levels, 12% had elevated ALT levels, and 51% had
leukocytosis (>10,000 103/µL) (15).
• A prospective study showed that 29% of patients with acute cholecystitis had hyperbilirubinemia.
The average bilirubin level in patients without common bile-duct stones was 2.7 mg/dL. The
average bilirubin level in patients with common bile-duct stones was 6.7 mg/dL (22).
• Two retrospective studies showed that leukocytosis was present in 60% and 63% of patients with
acute cholecystitis (14; 23).
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 5 of 32
Acute Cholecystitis
• In a review of 216 patients with acute calculous cholecystitis, elevated serum γ-glutamyl
transpeptidase >90 U/L was associated with a 33% chance of having choledocholithiasis (24).
• In a retrospective review of 177 patients aged 16 to 65 years who had right hypochondrial pain,
statistically significant predictors of acute cholecystitis were alkaline phosphatase, Murphy's sign,
elevated leukocyte count, and elevated bilirubin level (25).
Rationale
• Leukocytosis, mild LFT abnormalities, and mild hyperbilirubinemia are common in acute
cholecystitis.
• Leukocytosis may correlate with outcome in acute cholecystitis.
• Bilirubin >4 mg/dL is not a feature of uncomplicated acute cholecystitis.
Comments
• Bilirubin levels >4 mg/dL suggest possible common bile-duct stone, cholangitis, or Mirizzi's
syndrome, a rare condition in which a gallstone impacting the cystic duct obstructs the common
bile duct by edema and extrinsic compression.
• In elderly patients with acute cholecystitis and leukocytosis, consider early surgical evaluation
owing to the increased risk for developing gallbladder complications (16; 17).
2.5 Use imaging studies to establish the diagnosis.
Recommendations
• Obtain the following:
Transcutaneous ultrasound to diagnose acute cholecystitis
Cholescintigraphy scans (e.g., HIDA scan) as an alternative to diagnose acute cholecystitis or when
ultrasound is equivocal
CT scan when other studies are equivocal or when complications of acute cholecystitis are suspected
MRCP scan if there is suspicion of calculi in the bile duct
•
•
•
•
•
See
See
See
See
See
table Laboratory and Other Studies for Acute Cholecystitis.
figure Gallbladder Ultrasound Showing Gallstones.
figure Acalculous Cholecystitis.
figure Normal Gallbladder Ultrasound.
figure Gallstone Ileus.
Evidence
• A prospective study showed that when ultrasound revealed gallstones and a positive sonographic
Murphy's sign, the positive predictive value for acute cholecystitis was 92.2%. When the patient
had gallstones and gallbladder-wall thickening (≥3 mm), the positive predictive value was 95.2%
for acute cholecystitis (26).
• Multiple (>20) prospective and retrospective studies have showed ultrasound to have 81% to 98%
sensitivity and 70% to 98% specificity for acute cholecystitis (26; 27; 28; 29; 30).
• Various retrospective and prospective trials have compared ultrasound with HIDA scanning for the
diagnosis of acute cholecystitis. A retrospective analysis of patients with acute cholecystitis showed
ultrasound scans to be less sensitive than HIDA scans for initial diagnosis (48% vs. 86%) (30).
• A retrospective study showed ultrasound to have a sensitivity of 86% vs. 97% for HIDA scans (28).
• A retrospective study showed ultrasound to have an accuracy of 94% vs. 93% for HIDA scans (27).
• A meta-analysis from 1994 of 30 articles showed ultrasound to have 94% sensitivity and 78%
specificity, compared with HIDA scans, which have a 97% sensitivity and a 90% specificity for the
diagnosis of acute cholecystitis (29).
• A retrospective study showed that 50.9% of patients with acute cholecystitis showed evidence of a
thickened gallbladder wall on unenhanced CT scan. In addition, 66.7% of patients with this finding
had gangrenous cholecystitis on histology (31).
• A 2003 meta-analysis of 67 studies including 4711 patients showed that MRCP is a non-invasive
imaging test with excellent overall sensitivity (95%) and specificity (97%) for showing the level
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 6 of 32
Acute Cholecystitis
and presence of biliary obstruction, although it was less sensitive for identifying stones (88%) and
malignant lesions (92%) (32).
Rationale
• Both ultrasound and HIDA scans are accurate for the diagnosis of acute cholecystitis. The general
recommendation has been to obtain an ultrasound scan first, followed by an HIDA scan, if
necessary.
• The classic findings of acute cholecystitis on ultrasound are pericholecystic fluid and a thickened
gallbladder wall of 3 mm to 4 mm; sonographic Murphy's sign further confirms the diagnosis.
• The classic finding of acute cholecystitis on HIDA scan is non-visualization of the gallbladder.
• An enhanced CT scan can show gallstones, gallbladder-wall thickening, gallbladder distension,
pericholecystic fluid, and inflammation of the pericholecystic fat. An unenhanced CT scan can show
gallstones and a hyperdense gallbladder wall, which can suggest the presence of gangrenous
cholecystitis.
Comments
• Despite most organizations recommending ultrasound as the primary diagnostic tool for acute
cholecystitis, the literature shows that an HIDA scan has equal or better sensitivity and specificity;
however, cost and ease of access favor the use of ultrasound.
• Ultrasound can be less accurate in patients with ascites, hypoalbuminemia, hepatitis, obesity, and
heart failure.
• HIDA scans can give false-positive results in critically ill, fasting patients. Furthermore, HIDA scans
are not accurate with bilirubin levels >5 mg/dL, in which case more specialized tests, such as
DISIDA scan, can be used.
• CT scan should be reserved for cases of diagnostic dilemma and to detect possible complications of
acute cholecystitis (31).
• MRCP is commonly used to diagnose obstruction of the biliary tree caused by stones or malignant
lesions.
2.6 Consider the broad differential diagnosis.
Recommendations
• When considering the differential diagnosis of acute cholecystitis, include acute disease processes
on both sides of the diaphragm.
• See table Differential Diagnosis of Acute Cholecystitis.
Evidence
• Consensus.
Rationale
• Many intra-abdominal and thoracic conditions can mimic acute cholecystitis.
• The correct diagnosis must be made to separate routine conditions from emergent conditions.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 7 of 32
Acute Cholecystitis
Top
3. Consultation
Obtain surgical and possibly GI consultation to aid in the diagnosis.
Consult a surgeon and a gastroenterologist as needed for
management of patients.
3.1 Obtain surgical consultation for suspected cases of acute cholecystitis.
Recommendations
• Obtain surgical consultation to aid in diagnosing acute calculous and acalculous cholecystitis.
Evidence
• Consensus.
Rationale
• The differential diagnosis of acute cholecystitis is extensive; several surgical conditions can mimic
acute cholecystitis.
• Acute acalculous cholecystitis can present with subtle signs and symptoms in critically ill patients.
• A surgical consultant can establish a diagnosis and formulate a treatment plan.
3.2 Obtain GI consultation in certain cases.
Recommendations
• Obtain GI consultation in cases of suspected acute cholecystitis with a bilirubin level >4 mg/dL
and/or significantly elevated LFTs.
Evidence
• A prospective study of patients with acute cholecystitis who had hyperbilirubinemia and subsequent
biliary-tract exploration showed that 68.4% had common bile-duct stones (22).
Rationale
• Acute cholecystitis is generally not associated with significant jaundice or elevation of LFTs; these
findings suggest either common bile-duct stones or Mirizzi's syndrome, a rare condition in which a
gallstone impacting the cystic duct obstructs the common bile duct by edema and extrinsic
compression.
• MRC is useful in detecting stones in the common bile duct before or after cholecystectomy and may
be indicated.
• Endoscopic evaluation of the biliary tree may be warranted.
3.3 Obtain joint surgical and obstetric consultations in cases of suspected
acute cholecystitis during pregnancy.
Recommendations
• Obtain joint surgical and obstetric consultations in cases of suspected acute cholecystitis during
pregnancy.
Evidence
• In a study of 6221 women with gallstone-related hospitalization during pregnancy and postpartum,
76% were diagnosed with uncomplicated cholelithiasis, 16% with pancreatitis, 9% with acute
cholecystitis, and 8% with cholangitis. Seventy-three percent of the hospitalized women underwent
cholecystectomy and 5% underwent ERCP (39).
• In a prospective observational study of 122 patients with biliary disease (41 with acute
cholecystitis), conservative treatment failed in 69 (56.5%) patients and 54 of this group underwent
laparoscopic cholecystectomy during second trimester with no fetal or maternal mortality (40).
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 8 of 32
Acute Cholecystitis
• In a study of 49 patients admitted with an acute abdomen in pregnancy due to cholecystitis, 15
patients (31%) had emergency cholecystectomy within the first week. Thirty-four patients (69%)
were treated conservatively, of whom 24 relapsed many times and had to be readmitted to the
hospital. Of the remaining 10 patients on conservative management, 3 had emergency
cholecystectomy and 7 reached term safely. Maternal morbidity was significantly less in the
surgically treated group (P<0.0001), but there was no significant difference in perinatal outcome.
Although tocolytics were used in 13 cases, they did not improve the fetal outcome significantly and
had maternal and fetal side effects. This article concluded that early surgical intervention is
recommended and the use of tocolytics did not improve the perinatal outcome (41).
• In a population-based measurement of outcomes of cholecystectomy during pregnancy among
9714 pregnant women (89% underwent laparoscopic cholecystectomy), maternal and fetal
complication rates were 4.3% and 5.8%, respectively. Compared with pregnant women who
underwent open procedures, pregnant women who underwent laparoscopic cholecystectomy had
higher rates of surgical (19% vs. 10%), maternal (9% vs. 4%), and fetal (11% vs. 5%)
complications; longer length of stay (6 vs. 4 days); and higher cost ($13,198 vs. $9,229) (all
P<0.0001) (42).
Rationale
• Acute cholecystitis during pregnancy, although classically managed conservatively, can be
associated with recurrent symptoms requiring cholecystectomy.
• Acute cholecystitis during pregnancy can be safely treated with minimally invasive techniques
including percutaneous aspiration, cholecystostomy, laparoscopic cholecystectomy, and ERCP,
depending on the pregnancy trimester and underlying diagnosis.
3.4 Consult a surgeon immediately for management of patients.
Recommendations
• Consult a surgeon immediately for cholecystectomy.
• Consider surgical consult even in patients who are poor surgical candidates or deemed inoperable
who may benefit from cholecystectomy.
Evidence
• A prospective, randomized trial compared early cholecystectomy with delayed cholecystectomy in
patients with acute cholecystitis. In the delayed group, 13% of patients required emergent surgery
within 90 days owing to cholangitis, empyema, or peritonitis. Another 15% of patients developed
acute recurrent symptoms within the 90-day period (54).
• Two prospective, randomized, controlled trials have examined the issue of ‘early’ vs. ‘delayed’
laparoscopic cholecystectomy in acute cholecystitis. Both showed no difference in complication
rates, rates of conversion to open procedure, morbidity, or mortality. There was a shorter hospital
stay in the early group (P<0.001) (75; 76).
• A retrospective Veterans Administration study of acute cholecystitis patients with multiple medical
comorbidities evaluated 24 patients treated with cholecystostomy tubes (22 ultrasound/CT guided,
2 surgically placed), of whom 78% had clinical improvement within 48 hours. There was a 25%
periprocedural mortality rate (77).
• A retrospective study of inoperable patients treated with percutaneous cholecystostomy showed
98% successful biliary drainage; 96% of these patients showed clinical improvement within 72
hours, and 93% were discharged from the hospital with plans for a subsequent cholecystectomy
(65).
• A prospective study showed that 92.3% of patients with acute acalculous cholecystitis treated with
percutaneous cholecystostomy had good clinical response. All patients had subsequent catheter
removal without the need for cholecystectomy (66).
• A prospective study showed that 93.3% of patients with acute acalculous cholecystitis treated with
percutaneous cholecystostomy had significant clinical improvement; 13 of 14 patients who
responded had catheter removal and required no further therapy (67).
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 9 of 32
Acute Cholecystitis
Rationale
• Cholecystectomy is definitive therapy in most patients with acute cholecystitis.
• Early laparoscopic cholecystectomy can be safely done in most patients with acute cholecystitis.
• Inoperable and high-risk surgical candidates may need interventions, such as cholecystostomy,
which can be coordinated by a surgical consultant.
3.5 Consult a gastroenterologist in certain cases.
Recommendations
• Consult a gastroenterologist in patients for possible ERCP with acute cholecystitis and:
Jaundice
Common bile-duct dilation
Significantly elevated LFT levels
Significantly elevated pancreatic enzymes
Evidence
• A prospective, randomized study showed that 100% of patients presenting with acute cholangitis
had successful biliary drainage by ERCP. There was a trend toward fewer complications in the ERCP
group vs. the surgery group (P>0.05), and there was less mortality in the ERCP group (P<0.03)
(78).
• A retrospective study showed that 97% of patients with acute cholangitis were able to have
successful biliary drainage by ERCP. The overall mortality was 4.7% (compared with the quoted
historical, surgical mortality rate of 16.5% to 40%) (79).
Rationale
• Patients with acute cholecystitis and significantly elevated LFTs, bilirubin, pancreatic enzymes, or
dilated bile ducts may have common bile-duct stones or Mirizzi's syndrome.
• ERCP may be diagnostic and/or therapeutic in this subset of patients.
Comments
• MRC is a non-invasive method of detecting stones in the common bile duct in patients with risk
factors for common bile-duct calculi, thereby helping avoid ERCP, which is an invasive test with
potential complications. A prospective study evaluated the predictive value of MRC in detecting
stones in the common bile duct before laparoscopic cholecystectomy. MRC had a sensitivity of
100%, a specificity of 96.3%, a positive predictive value of 91.8%, and a negative predictive value
of 100% for the detection of common bile-duct stones (80).
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 10 of 32
Acute Cholecystitis
Top
4. Hospitalization
Hospitalize patients with acute cholecystitis.
4.1 Hospitalize patients with acute cholecystitis for definitive diagnosis and
treatment.
Recommendations
• Hospitalize patients to:
Provide analgesia, hydration, supportive care, and possibly antibiotics
Obtain surgical consultation
Prepare patient for possible cholecystectomy
• See Therapy.
Evidence
• Consensus.
Rationale
• Many patients with acute cholecystitis will have nausea, vomiting, or anorexia requiring iv
hydration and supportive care, and many will also require parenteral analgesia.
• Most patients will require definitive surgical therapy.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 11 of 32
Acute Cholecystitis
Top
5. Therapy
Consider cholecystectomy as definitive therapy.
5.1 Consider the use of antibiotics in certain patients.
Recommendations
• Consider using broad-spectrum antibiotics in acute cholecystitis patients with sepsis, fever,
leukocytosis, or evidence of complications.
• See table Drug Treatment for Acute Cholecystitis.
Evidence
• A prospective study of 467 patients with acute cholecystitis showed positive bile cultures in 46%;
the most common organisms were E. coli, Klebsiella sp., group D Streptococcus sp., and
Enterobacter sp. Patients aged over 60 years had the highest rate of biliary infection (43).
• Cases of acute cholecystitis are reported to be caused by such organisms as Vibrio cholerae (44),
Haemophilus influenzae (45), Moellerella wisconsensis (46), Salmonella sp. (47), Cytomegalovirus
(48), Cellulomonas denverensis (49), and Candida lusitaniae (50).
• A retrospective study of 302 patients with acute cholecystitis showed no difference in local septic
complications, such as empyema or pericholecystic abscess, in those treated with or without
antibiotics. There was a lower incidence of wound infections and postoperative bacteremia in
patients treated with antibiotics (51).
Rationale
• A significant percentage of patients with acute cholecystitis will have positive blood and bile
cultures. Antibiotics would be expected to benefit this group.
Comments
• Definitive evidence regarding the use of antibiotics in acute cholecystitis is lacking; however, it
would seem prudent to consider using antibiotics in toxic-appearing patients.
• The recommended regimens vary from single- to triple-coverage; the choice of antibiotic should be
based on suspected organisms and local antibiotic resistance patterns.
5.2 Ensure appropriate use of pain medications.
Recommendations
• Consider using:
NSAIDs in patients with biliary colic or acute cholecystitis with mild to moderate abdominal pain
Narcotic analgesics in patients with moderate to severe abdominal pain
• See module Pain.
Evidence
• Retrospective studies of patients presenting with acute cholecystitis show that abdominal pain
occurs in 73.5% (14) and abdominal tenderness occurs in 85% (18).
• A randomized, double-blind study of diclofenac showed satisfactory pain relief and decrease in
progression to acute cholecystitis. Four of 27 patients who received diclofenac developed acute
cholecystitis compared with 11 of 26 patients who received placebo (P=0.04) (8).
• A 2008 systematic review and meta-analysis that included seven randomized, controlled trials
(n=349 patients) assessing the efficacy of NSAIDs in comparison to other analgesic agents in the
treatment of biliary colic showed NSAIDs to be the analgesics of choice for biliary colic in limiting
the progression of colic to acute cholecystitis (7).
• A randomized, double-blind study evaluated the efficacy of iv ketorolac compared with butorphanol
for the treatment of biliary colic pain in the emergency department. Patients presenting with
abdominal pain suspected to be biliary colic were randomized to receive either ketorolac, 30 mg iv,
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 12 of 32
Acute Cholecystitis
or butorphanol, 1 mg iv. The mean (+/- SD) pain score (visual analogue scale) in the butorphanol
group decreased from 7.1 (+/-1.7) to 2.1 (+/-2.2) after 30 minutes. The mean (+/-SD) pain score
in the ketorolac group decreased from 7.4 (+/-2.0) to 3.1 (+/-3.3) after 30 minutes. This study
showed that both ketorolac and butorphanol provide pain relief in biliary colic and were suitable
especially in patients who require HIDA scan (52).
Rationale
• Over 80% of patients with acute cholecystitis present with abdominal pain or tenderness, and pain
medications can provide analgesia while awaiting definitive therapy.
• NSAIDs provide pain relief in biliary colic and may decrease the risk for progression to acute
cholecystitis.
Comments
• A prospective, non-blinded study using sphincter of Oddi manometry showed that morphine
increased sphincter phasic wave amplitude and basal pressure (P<0.05) (53).
• Older studies suggested that meperidine might be preferable to morphine in the treatment of pain
in patients with acute cholecystitis because it increases pressure at the sphincter of Oddi less than
other opiates, but evidence is not strong enough to support a recommendation of one opiate
analgesic over another. Meperidine should be avoided in elderly patients and those with renal
dysfunction because of possible accumulation of a toxic metabolite with neuroexcitatory effects.
5.3 Consider early cholecystectomy.
Recommendations
• Consider laparoscopic cholecystectomy to be the preferred surgical approach in patients with acute
cholecystitis.
• Perform cholecystectomy within 24 to 48 hours of diagnosis.
• Note that technical aspects, such as anatomy and complications, may require an open surgical
approach in certain patients.
Evidence
• A prospective, randomized trial compared early cholecystectomy with delayed cholecystectomy in
patients with acute cholecystitis. In the delayed group, 13% of patients required emergent surgery
within 90 days owing to cholangitis, empyema, or peritonitis. Another 15% of patients developed
acute recurrent symptoms within the 90-day period (54).
• A retrospective study evaluated 609 patients with acute cholecystitis treated by laparoscopic
cholecystectomy. The overall complication rate was 15%; specific complication rates were bile
leaks, 1.97%, and biliary-tract injury, 0.66%; mortality was 0.66%. These rates were comparable
to previous open cholecystectomy series (55).
• A randomized, controlled trial comparing open and laparoscopic cholecystectomy in acute
cholecystitis showed a significantly lower postoperative complication rate (P=0.0048), shorter
hospitalization (P=0.0063), and lower hospital cost for laparoscopy (56).
• A 2008 meta-analysis examined the issue of ‘early’ vs. ‘delayed’ laparoscopic cholecystectomy in
patients with acute cholecystitis. Early laparoscopic cholecystectomy resulted in a significantly
shorter total hospital stay at the cost of a significantly longer operation time, with no significant
difference in conversion rates or complications (57).
• A 2010 systematic review with meta-analysis of randomized clinical trials of early laparoscopic
cholecystectomy (done within 1 week of onset of symptoms) vs. delayed laparoscopic
cholecystectomy (done at least 6 weeks after symptoms settled) for acute cholecystitis, which
included five trials with 451 patients, showed no significant difference between the two groups in
terms of bile-duct injury (RR, 0.64 [CI, 0.15 to 2.65]) or conversion to open cholecystectomy (RR,
0.88 [CI, 0.62 to 1.25]). The total hospital stay was 4 days shorter for early laparoscopic
cholecystectomy (mean difference, -4.12 [CI, -5.22 to -3.03] days). Early laparoscopic
cholecystectomy during acute cholecystitis appears safe and shortens the total hospital stay (58).
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 13 of 32
Acute Cholecystitis
• A 2008 Cochrane review, which included five trials with 429 patients randomly assigned to the daycase group (n=215) and overnight-stay group (n=214), showed no significant difference between
the two groups regarding morbidity, prolongation of hospital stay, readmission rates, pain, quality
of life, patient satisfaction, and return to normal activity and work. The day-case elective
laparoscopic cholecystectomy was safe and effective in selected patients with symptomatic
gallstones who had no or minimal systemic disease and were within easy reach of the hospital
(59).
• In a prospective study from the UK that included 106 patients who had day-case laparoscopic
cholecystectomy, 84% were discharged on the day of surgery. Mean surgery time was 62 minutes,
with an average total stay on the day-case unit of 426 minutes. Both the readmission rate after
surgery and rate of conversion to open surgery were 2%. Introduction of day-case laparoscopic
cholecystectomy in the UK was feasible and acceptable to patients (60).
• Cholecystectomy using rigid-hybrid transvaginal natural orifice transluminal endoscopic surgery
reduces abdominal-wall incisions and might decrease surgical trauma by combining endoluminal
access and laparoscopic techniques. In one study, 102 of 137 consecutive patients (74.5 %) with
symptomatic cholecystolithiasis (n=74) or cholecystitis (n=28) were scheduled for this type of
surgery. There were no intraoperative complications. At 6 weeks postoperatively, there were fewer
dyspareunia symptoms than preoperatively (P=0.049). This technique is feasible and safe in
routine practice for symptomatic cholecystolithiasis and acute cholecystitis (61).
• Percutaneous transhepatic gallbladder drainage is a procedure to resolve acute cholecystitis, which
decreases the technical difficulty of laparoscopic cholecystectomy and facilitates successful surgery
when a patients' condition improves. Early laparoscopic cholecystectomy (within 72 hours, n=21)
vs. delayed (after 72 hours; n=46) laparoscopic cholecystectomy after percutaneous transhepatic
gallbladder drainage showed a higher complication rate and longer operating time, but shorter
hospital stay in the former group (62).
• In a retrospective study involving 809 patients with acute cholecystitis, laparoscopic
cholecystectomy (done in 82% of patients) was associated with significantly better outcomes,
including shorter postsurgical stay and fewer complications compared with open cholecystectomy
and cholecystostomy (63).
Rationale
• Laparoscopic cholecystectomy is safer, less expensive, and associated with shorter hospitalizations
than open procedures.
• Early cholecystectomy is associated with a shorter recovery period and fewer complications, such
as gangrene and empyema of the gallbladder.
• Acute cholecystitis and/or other serious complications of gallstone disease can recur in untreated
patients.
Comments
• The exact surgical approach may vary based on local surgical expertise.
• Patients should understand that conversion from a laparoscopic to an open procedure may be
necessary.
• Day-case laparoscopic cholecystectomy is not suitable for acute cholecystitis.
• Natural orifice transluminal endoscopic surgery is being increasingly practiced with encouraging
results.
• Single-incision laparoscopic cholecystectomy is a variation in which trocar scars are hidden in the
umbilicus. In a study including 205 cases of single-incision laparoscopic cholecystectomy, the mean
operating time was 60 minutes and complications occurred in 4% of cases. Single-incision
laparoscopic cholecystectomy can be done safely and offers a better cosmetic result, which may
lead to greater patient satisfaction (64).
5.4 Consider cholecystostomy in certain patients.
Recommendations
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 14 of 32
Acute Cholecystitis
• Consider cholecystostomy as temporizing or definitive therapy for inoperable or high-risk patients
with calculous or acalculous cholecystitis.
Evidence
• A retrospective study of inoperable patients treated with percutaneous cholecystostomy showed
98% successful biliary drainage; 96% of these patients showed clinical improvement within 72
hours, and 93% were discharged from the hospital with plans for a subsequent cholecystectomy
(65).
• A prospective study showed that 92.3% of patients with acute acalculous cholecystitis treated with
percutaneous cholecystostomy had good clinical response. All patients had subsequent catheter
removal without the need for cholecystectomy (66).
• A prospective study showed that 93.3% of patients with acute acalculous cholecystitis treated with
percutaneous cholecystostomy had significant clinical improvement; 13 of 14 patients who
responded had catheter removal and required no further therapy (67).
• A retrospective study of 45 patients having cholecystostomy for acute cholecystitis showed a 100%
technically successful gallbladder drainage rate. 78% of the patients improved clinically within 5
days (68).
• A prospective study randomizing patients with acute calculous cholecystitis into those having
percutaneous cholecystostomy followed by an early laparoscopic cholecystectomy (n=31) and
those having an initial conservative treatment followed by a delayed laparoscopic cholecystectomy
(n=30) showed significantly shorter hospital stay and lower cost in the first group (69).
• In a study involving 106 patients with acute cholecystitis, percutaneous cholecystostomy led to
clinical improvement in 72 patients (68%), whereas 34 (32%) showed no improvement or clinical
deterioration. Patients who presented to the emergency department primarily with acute
cholecystitis fared better (84% of patients showed improvement) than inpatients (34% showed
improvement; P<0.0001). Gallstones were identified in 54% of patients who presented to the
emergency department, whereas acalculous cholecystitis was more commonly diagnosed in
inpatients (54%). Patients with sepsis had worse outcomes overall (P<0.0001). Patients fare better
after percutaneous cholecystostomy for acute cholecystitis when the disease is primary and not
precipitated by concurrent illness (70).
Rationale
• The mortality rate of critically ill patients having cholecystectomy for acute cholecystitis can be
10% to 30%.
• Because patients with acute acalculous cholecystitis are often critically ill and may not be operative
candidates, cholecystostomy may allow biliary drainage that may temporize the patient until
surgery can be safely done or even provide definitive therapy for the patient.
• Acalculous cholecystitis may resolve when the precipitating factors, such as TPN, sepsis, shock, or
fasting, improve.
• Cholecystostomy may allow time to resolve these precipitating factors and thus be curative.
Comments
• Cholecystostomy is indicated in high-risk patients who are not candidates for cholecystectomy.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 15 of 32
Acute Cholecystitis
Top
6. Patient Education
Inform patients of the natural history of acute cholecystitis.
6.1 Inform patients of the natural history and therapeutic options for acute
cholecystitis.
Recommendations
• Explain the natural course of acute cholecystitis.
• Inform the patient of the treatment options available.
• Explain why surgical options are preferred in most cases.
Evidence
• A retrospective study of patients at initial presentation with acute cholecystitis showed 7.1% had
gangrenous cholecystitis, 6.3% had empyema of the gallbladder, 3.3% had gallbladder perforation,
and 0.5% had emphysematous cholecystitis (71).
• A prospective, randomized trial compared early cholecystectomy with delayed cholecystectomy in
patients with acute cholecystitis. In the delayed group, 13% of patients required emergent surgery
within 90 days owing to cholangitis, empyema, or peritonitis. Another 15% of patients developed
acute recurrent symptoms within the 90-day period (54).
• A prospective, randomized clinical trial compared the outcomes of early (within 7 days of onset of
symptoms) with delayed (6 to 8 weeks after initial conservative treatment) laparoscopic
cholecystectomy. Twenty-six percent of patients in the delayed cholecystectomy group required
emergency cholecystectomy for failure of conservative treatment. There was no significant
difference in the conversion rate, operating time, or complications. The greatest advantage was a
reduced length of hospital stay in the early cholecystectomy group (72).
• A 2008 meta-analysis of 20 randomized, controlled trials including 3860 patients showed day-case
laparoscopic cholecystectomy to be safe in a selected group of patients who do not have acute
cholecystitis, bile-duct stones, or previous upper-abdominal surgery (73).
• In 185 adult patients admitted with acute cholecystitis (mean age 71 years; 80% had more than
one comorbidity), percutaneous cholecystostomy was done in 78% of cases and open surgical
cholecystostomy was done in 22%. In both groups, 85% patients underwent laparoscopic
cholecystectomy as definitive treatment, thereby confirming that cholecystostomy is a useful
alternative to open cholecystectomy in patients with acute cholecystitis that allows patients to
undergo laparoscopic cholecystectomy at a later date (74).
Rationale
• The risk for advanced disease and complications at the time of presentation is significant.
• The risk for recurrent acute cholecystitis in the untreated patient is significant.
• Surgical therapies are definitive, effective, and safe.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 16 of 32
Acute Cholecystitis
Top
7. Follow-up
Schedule follow-up of patients treated for acute cholecystitis based
on hospital course.
7.1 Ensure that patients who have had cholecystectomy follow-up with their
surgeon.
Recommendations
• Advise patients to follow-up with their surgeon routinely, and immediately if they have right upper
quadrant pain, fever, or wound-site complaints which suggest postoperative biliary tract
complications such as retained bile-duct stone, bile leak, or infection.
Evidence
• Two prospective, randomized studies showed overall complication rates of 13% (75) and 9% (76)
in patients having early laparoscopic cholecystectomy for acute cholecystitis.
• A retrospective literature review showed that the overall risk for biliary injury during laparoscopic
cholecystectomy (for any indication) is 2.58%; major bleeding occurred in 1.38% of cases, wound
infection in 0.6%, bile leak in 0.4%, biliary injury in 0.2%, and bowel injury in 0.16% (81). A
retrospective, single-center study showed bile-duct injury occurring in 0.59% of patients having
laparoscopic cholecystectomy for any indication (82).
Rationale
• Laparoscopic cholecystectomy carries risk for postoperative complications; these risks are higher in
patients having the procedure for acute cholecystitis.
• The surgeon should watch for signs and symptoms of biliary-tract complications and wound
infections.
Comments
• The surgeon should determine the postoperative follow-up schedule.
7.2 Re-evaluate patients who have had cholecystostomy or medical
management.
Recommendations
• In consultation with a surgeon, re-evaluate patients with acute cholecystitis who have had:
Cholecystostomy or medical therapy alone for subsequent cholecystectomy
Medical therapy with UDCA to dissolve remaining symptomatic gallstones
ERCP with or without sphincterotomy to remove a retained bile-duct stone
• Ask about recurrent symptoms of right upper quadrant pain and biliary colic, fever, and jaundice.
Evidence
• A prospective, randomized trial compared early cholecystectomy with delayed cholecystectomy in
patients with acute cholecystitis. In the delayed group, 13% of patients required emergent surgery
within 90 days owing to cholangitis, empyema, or peritonitis. Another 15% of patients developed
acute recurrent symptoms within the 90-day period (54).
• A retrospective study showed that 61.5% of patients with acute calculous cholecystitis who were
temporized with a cholecystostomy tube were able to have subsequent elective cholecystectomy.
Surgical morbidity was 12.5% with no mortalities (83).
Rationale
• Many patients treated conservatively for acute calculous cholecystitis will have recurrent significant
complications.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 17 of 32
Acute Cholecystitis
• Cholecystectomy provides definitive therapy.
Comments
• Extremely poor-risk surgical candidates can be maintained with a permanent cholecystostomy
drainage tube.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 18 of 32
Acute Cholecystitis
Top
References
1. May GR, Sutherland LR, Shaffer EA. Efficacy of bile acid therapy for gallstone dissolution: a meta-analysis of randomized trials.
Aliment Pharmacol Ther. 1993;7:139-48. (PMID: 8485266)
2. Erlinger S, Le Go A, Husson JM, Fevery J. Franco-Belgian cooperative study of ursodeoxycholic acid in the medical dissolution of
gallstones: a double-blind, randomized, dose-response study, and comparison with chenodeoxycholic acid. Hepatology.
1984;4:308-14. (PMID: 6706305)
3. Fischer S, Muller I, Zundt BZ, Jungst C, Meyer G, Jungst D. Ursodeoxycholic acid decreases viscosity and sedimentable fractions
of gallbladder bile in patients with cholesterol gallstones. Eur J Gastroenterol Hepatol. 2004;16:305-11. (PMID: 15195895)
4. Uy MC, Talingdan-Te MC, Espinosa WZ, Daez ML, Ong JP. Ursodeoxycholic acid in the prevention of gallstone formation after
bariatric surgery: a meta-analysis. Obes Surg. 2008;18:1532-8. (PMID: 18574646)
5. Cho JY, Han HS, Yoon YS, Ahn KS. Risk factors for acute cholecystitis and a complicated clinical course in patients with
symptomatic cholelithiasis. Arch Surg. 2010;145:329-33; discussion 333. (PMID: 20404281)
6. Venneman NG, Besselink MG, Keulemans YC, Vanberge-Henegouwen GP, Boermeester MA, Broeders IA, et al. Ursodeoxycholic
acid exerts no beneficial effect in patients with symptomatic gallstones awaiting cholecystectomy. Hepatology. 2006;43:127683. (PMID: 16729326)
7. Basurto Oña X, Robles Perea L. [Anti-inflammatory drugs for biliary colics: systematic review and meta-analysis of randomized
controlled trials.] Gastroenterol Hepatol. 2008;31:1-7. (PMID: 18218271)
8. Akriviadis EA, Hatzigavriel M, Kapnias D, Kirmlidis J, Markantas A, Garyfallos A. Treatment of biliary colic with diclofenac: a
randomized, double-blind, placebo-controlled study. Gastroenterology. 1997;113:225-31. (PMID: 9207282)
9. Kumar A, Deed JS, Bhasin B, Kumar A, Thomas S. Comparison of the effect of diclofenac with hyoscine-N-butylbromide in the
symptomatic treatment of acute biliary colic. ANZ J Surg. 2004;74:573-6. (PMID: 15230794)
10. Thistle JL, Cleary PA, Lachin JM, Tyor MP, Hersh T. The natural history of cholelithiasis: the National Cooperative Gallstone
Study. Ann Intern Med. 1984;101:171-5. (PMID: 6742647)
11. Ransohoff DF, Gracie WA. Treatment of gallstones. Ann Intern Med. 1993;119(7 Pt 1):606-19. Review. (PMID: 8363172)
12. Gurusamy KS, Samraj K. Cholecystectomy versus no cholecystectomy in patients with silent gallstones. Cochrane Database
Syst Rev. 2007;(1):CD006230. (PMID: 17253585)
13. Nikfarjam M, Niumsawatt V, Sethu A, Fink MA, Muralidharan V, Starkey G, et al. Outcomes of contemporary management of
gangrenous and non-gangrenous acute cholecystitis. HPB (Oxford). 2011;13:551-8. (PMID: 21762298)
14. Singer AJ, McCracken G, Henry MC, Thode HC Jr, Cabahug CJ. Correlation among clinical, laboratory, and hepatobiliary
scanning findings in patients with suspected acute cholecystitis. Ann Emerg Med. 1996;28:267-72. (PMID: 8780468)
15. Raine PA, Gunn AA. Acute cholecystitis. Br J Surg. 1975;62:697-700. (PMID: 1174813)
16. Wang AJ, Wang TE, Lin CC, Lin SC, Shih SC. Clinical predictors of severe gallbladder complications in acute acalculous
cholecystitis. World J Gastroenterol. 2003;9:2821-3. (PMID: 14669342)
17. Fagan SP, Awad SS, Rahwan K, Hira K, Aoki N, Itani KM, et al. Prognostic factors for the development of gangrenous
cholecystitis. Am J Surg. 2003;186:481-5. (PMID: 14599611)
18. Staniland JR, Ditchburn J, De Dombal FT. Clinical presentation of acute abdomen: study of 600 patients. Br Med J. 1972;3:3938. (PMID: 4506871)
19. Halasz NA. Counterfeit cholecystitis, a common diagnostic dilemma. Am J Surg. 1975;130:189-93. (PMID: 1155733)
20. Kalliafas S, Ziegler DW, Flancbaum L, Choban PS. Acute acalculous cholecystitis: incidence, risk factors, diagnosis, and
outcome. Am Surg. 1998;64:471-5. (PMID: 9585788)
21. Eggermont AM, Lameris JS, Jeekel J. Ultrasound-guided percutaneous transhepatic cholecystostomy for acute acalculous
cholecystitis. Arch Surg. 1985;120:1354-6. (PMID: 3904672)
22. Dumont AE. Significance of hyperbilirubinemia in acute cholecystitis. Surg Gynecol Obstet. 1976;142:855-7. (PMID: 936028)
23. Gruber PJ, Silverman RA, Gottesfeld S, Flaster E. Presence of fever and leukocytosis in acute cholecystitis. Ann Emerg Med.
1996;28:273-7. (PMID: 8780469)
24. Peng WK, Sheikh Z, Paterson-Brown S, Nixon SJ. Role of liver function tests in predicting common bile duct stones in acute
calculous cholecystitis. Br J Surg. 2005;92:1241-7. (PMID: 16078299)
25. Mills LD, Mills T, Foster B. Association of clinical and laboratory variables with ultrasound findings in right upper quadrant
abdominal pain. South Med J. 2005;98:155-61. (PMID: 15759944)
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 19 of 32
Acute Cholecystitis
26. Ralls PW, Colletti PM, Lapin SA, Chandrasoma P, Boswell WD Jr, Ngo C, et al. Real-time sonography in suspected acute
cholecystitis. Prospective evaluation of primary and secondary signs. Radiology. 1985;155:767-71. (PMID: 3890007)
27. Matolo NM, Stadalnik RC, McGahan JP. Comparison of ultrasonography, computerized tomography, and radionuclide imaging in
the diagnosis of acute and chronic cholecystitis. Am J Surg. 1982;144:676-81. (PMID: 7149126)
28. Fink-Bennett D, Freitas JE, Ripley SD, Bree RL. The sensitivity of hepatobiliary imaging and real-time ultrasonography in the
detection of acute cholecystitis. Arch Surg. 1985;120:904-6. (PMID: 3893388)
29. Shea JA, Berlin JA, Escarce JJ, Clarke JR, Kinosian BP, Cabana MD, et al. Revised estimates of diagnostic test sensitivity and
specificity in suspected biliary tract disease. Arch Intern Med. 1994;154:2573-81. (PMID: 7979854)
30. Kalimi R, Gecelter GR, Caplin D, Brickman M, Tronco GT, Love C, et al. Diagnosis of acute cholecystitis: sensitivity of
sonography, cholescintigraphy, and combined sonography-cholescintigraphy. J Am Coll Surg. 2001;193:609-13. (PMID:
11768676)
31. Cheng SM, Ng SP, Shih SL. Hyperdense gallbladder wall sign: an overlooked sign of acute cholecystitis on unenhanced CT
examination. Clin Imaging. 2004;28:128-31. (PMID: 15050226)
32. Romagnuolo J, Bardou M, Rahme E, Joseph L, Reinhold C, Barkun AN. Magnetic resonance cholangiopancreatography: a metaanalysis of test performance in suspected biliary disease. Ann Intern Med. 2003;139:547-57. (PMID: 14530225)
33. Working Party of the British Society of Gastroenterology; Association of Surgeons of Great Britain and Ireland; Pancreatic
Society of Great Britain and Ireland; Association of Upper GI Surgeons of Great Britain and Ireland. UK guidelines for the
management of acute pancreatitis. Gut. 2005;54 Suppl 3:iii1-9. (PMID: 15831893)
34. Mergen H, Genç H, Tavusbay C. Assessment of liver hydatid cyst cases--10 years experience in Turkey. Trop Doct.
2007;37:54-6. (PMID: 17326896)
35. Wani I. Gallbladder ascariasis. Turk J Gastroenterol. 2011;22:178-82. (PMID: 21796555)
36. Kelly TR. Benign liver tumors: presenting profiles and treatment. Am Surg. 1981;46:398-402. (PMID: 7447174)
37. Boer J, Boerma D, de Vries Reilingh TS. A gallbladder torsion presenting as acute cholecystitis in an elderly woman: A case
report. J Med Case Rep. 2012;5:588. (PMID: 22185300)
38. Choi YS. Gallbladder hemorrhage mimicking acute cholecystitis in a patient under antiplatelet therapy. Z Gastroenterol.
2012;50:285-7. (PMID: 22383284)
39. Ko CW. Risk factors for gallstone-related hospitalization during pregnancy and the postpartum. Am J Gastroenterol.
2006;101:2263-8. (PMID: 17032191)
40. Chiappetta Porras LT, Nápoli ED, Canullán CM, Quesada BM, Roff HE, Alvarez Rodríguez J, et al. Minimally invasive
management of acute biliary tract disease during pregnancy. HPB Surg. 2009;2009:829020. (PMID: 19606252)
41. Elamin Ali M, Yahia Al-Shehri M, Abu-Eshy S, Cheema MA, Mustafa Z, Sadek A. Is surgical intervention in acute cholecystitis in
pregnancy justified? J Obstet Gynaecol. 2004;17:435-8. (PMID: 15511915)
42. Kuy S, Roman SA, Desai R, Sosa JA. Outcomes following cholecystectomy in pregnant and nonpregnant women. Surgery.
2009;146:358-66. (PMID: 19628096)
43. Csendes A, Burdiles P, Maluenda F, Diaz JC, Csendes P, Mitru N. Simultaneous bacteriologic assessment of bile from gallbladder
and common bile duct in control subjects and patients with gallstones and common duct stones. Arch Surg. 1996;131:389-94.
(PMID: 8615724)
44. Vogt AP, Doshi RK, Higgins JE, Burd EM, Ribner BS, Kraft CS. Acute cholecystitis caused by nontoxigenic Vibrio cholerae O1
Inaba. J Clin Microbiol. 2010;48:1002-4. (PMID: 20053858)
45. Matsubayashi T, Tobayama S, Machida H. Acute cholecystitis caused by Haemophilus influenzae in a child. J Infect Chemother.
2009;15:325-7. (PMID: 19856072)
46. Aller AI, Castro C, Medina MJ, González MT, Sevilla P, Morilla MD, et al. Isolation of Moellerella wisconsensis from blood culture
from a patient with acute cholecystitis. Clin Microbiol Infect. 2009;15:1193-4. (PMID: 19732083)
47. khan FY, Elouzi EB, Asif M. Acute acalculous cholecystitis complicating typhoid fever in an adult patient: a case report and
review of the literature. Travel Med Infect Dis. 2009;7:203-6. (PMID: 19717100)
48. Drage M, Reid A, Callaghan CJ, Baber Y, Freeman S, Huguet E, et al. Acute cytomegalovirus cholecystitis following renal
transplantation. Am J Transplant. 2009;9:1249-52. (PMID: 19422351)
49. Ohtaki H, Ohkusu K, Sawamura H, Ohta H, Inoue R, Iwasa J, et al. First report of acute cholecystitis with sepsis caused by
Cellulomonas denverensis. J Clin Microbiol. 2009;47:3391-3. (PMID: 19656981)
50. Yildirim M, Ozaydin I, Sahin I, Yasar M. Acute calculous cholecystitis caused by Candida lusitaniae: an unusual causative
organism in a patient without underlying malignancy. Jpn J Infect Dis. 2008;61:138-9. (PMID: 18362405)
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 20 of 32
Acute Cholecystitis
51. Kune GA, Burdon JG. Are antibiotics necessary in acute cholecystitis? Med J Aust. 1975;2:627-30. (PMID: 1207539)
52. Olsen JC, McGrath NA, Schwarz DG, Cutcliffe BJ, Stern JL. A double-blind randomized clinical trial evaluating the analgesic
efficacy of ketorolac versus butorphanol for patients with suspected biliary colic in the emergency department. Acad Emerg
Med. 2008;15:718-22. (PMID: 18637080)
53. Helm JF, Venu RP, Geenen JE, Hogan WJ, Dodds WJ, Toouli J, et al. Effects of morphine on the human sphincter of Oddi. Gut.
1988;29:1402-7. (PMID: 3197985)
54. Jarvinen HJ, Hastbacka J. Early cholecystectomy for acute cholecystitis: a prospective randomized study. Ann Surg.
1980;191:501-5. (PMID: 6445180)
55. Navez B, Mutter D, Russier Y, Vix M, Jamali F, Lipski D, et al. Safety of laparoscopic approach for acute cholecystitis:
retrospective study of 609 cases. World J Surg. 2001;25:1352-6. (PMID: 11596902)
56. Kiviluoto T, Siren J, Luukkonen P, Kivilaakso E. Randomised trial of laparoscopic versus open cholecystectomy for acute and
gangrenous cholecystitis. Lancet. 1998;351:321-5. (PMID: 9652612)
57. Siddiqui T, MacDonald A, Chong PS, Jenkins JT. Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a
meta-analysis of randomized clinical trials. Am J Surg. 2008;195:40-7. (PMID: 18070735)
58. Gurusamy K, Samraj K, Gluud C, Wilson E, Davidson BR. Meta-analysis of randomized controlled trials on the safety and
effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg. 2010;97:141-50. (PMID:
20035546)
59. Gurusamy KS, Junnarkar S, Farouk M, Davidson BR. Day-case versus overnight stay for laparoscopic cholecystectomy.
Cochrane Database Syst Rev. 2008;(3):CD006798. (PMID: 18677781)
60. Briggs CD, Irving GB, Mann CD, Cresswell A, Englert L, Peterson M, et al. Introduction of a day-case laparoscopic
cholecystectomy service in the UK: a critical analysis of factors influencing same-day discharge and contact with primary care
providers. Ann R Coll Surg Engl. 2009;91:583-90. (PMID: 19558787)
61. Linke GR, Tarantino I, Hoetzel R, Warschkow R, Lange J, Lachat R, et al. Transvaginal rigid-hybrid NOTES cholecystectomy:
evaluation in routine clinical practice. Endoscopy. 2010;42:571-5. (PMID: 20432208)
62. Han IW, Jang JY, Kang MJ, Lee KB, Lee SE, Kim SW. Early versus delayed laparoscopic cholecystectomy after percutaneous
transhepatic gallbladder drainage. J Hepatobiliary Pancreat Sci. 2012;19:187-93. (PMID: 21938408)
63. Wiseman JT, Sharuk MN, Singla A, Cahan M, Litwin DE, Tseng JF, et al. Surgical management of acute cholecystitis at a tertiary
care center in the modern era. Arch Surg. 2010;145:439-44. (PMID: 20479341)
64. Vemulapalli P, Agaba EA, Camacho D. Single incision laparoscopic cholecystectomy: a single center experience. Int J Surg.
2011;9:410-3. (PMID: 21515426)
65. Spira RM, Nissan A, Zamir O, Cohen T, Fields SI, Freund HR. Percutaneous transhepatic cholecystostomy and delayed
laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis. Am J Surg. 2002;183:62-6. (PMID:
11869705)
66. Sugiyama M, Tokuhara M, Atomi Y. Is percutaneous cholecystostomy the optimal treatment for acute cholecystitis in the very
elderly? World J Surg. 1998;22:459-63. (PMID: 9564288)
67. Shirai Y, Tsukada K, Kawaguchi H, Ohtani T, Muto T, Hatakeyama K. Percutaneous transhepatic cholecystostomy for acute
acalculous cholecystitis. Br J Surg. 1993;80:1440-2. (PMID: 8252358)
68. Byrne MF, Suhocki P, Mitchell RM, Pappas TN, Stiffler HL, Jowell PS, et al. Percutaneous cholecystostomy in patients with acute
cholecystitis: experience of 45 patients at a US referral center. J Am Coll Surg. 2003;197:206-11. (PMID: 12892798)
69. Akyürek N, Salman B, Yüksel O, Tezcaner T, Irkörücü O, Yücel C, Oktar S, Tatlicioglu E. Management of acute calculous
cholecystitis in high-risk patients: percutaneous cholecystotomy followed by early laparoscopic cholecystectomy. Surg
Laparosc Endosc Percutan Tech. 2005 Dec;15(6):315-20. (PMID: 16340560)
70. Joseph T, Unver K, Hwang GL, Rosenberg J, Sze DY, Hashimi S, et al. Percutaneous cholecystostomy for acute cholecystitis:
ten-year experience. J Vasc Interv Radiol. 2012;23:83-8.e1. (PMID: 22133709)
71. Bedirli A, Sakrak O, Sozuer EM, Kerek M, Guler I. Factors effecting the complications in the natural history of acute
cholecystitis. Hepatogastroenterology. 2001;48:1275-8. (PMID: 11677945)
72. Johansson M, Thune A, Blomqvist A, Nelvin L, Lundell L. Management of acute cholecystitis in the laparoscopic era: results of a
prospective, randomized clinical trial. J Gastrointest Surg. 2003;7:642-5. (PMID: 12850677)
73. Tenconi SM, Boni L, Colombo EM, Dionigi G, Rovera F, Cassinotti E. Laparoscopic cholecystectomy as day-surgery procedure:
current indications and patients' selection. Int J Surg. 2008;6 Suppl 1:S86-8. (PMID: 19167938)
74. Cherng N, Witkowski ET, Sneider EB, Wiseman JT, Lewis J, Litwin DE, et al. Use of cholecystostomy tubes in the management
of patients with primary diagnosis of acute cholecystitis. J Am Coll Surg. 2012;214:196-201. (PMID: 22192897)
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 21 of 32
Acute Cholecystitis
75. Lo CM, Liu CL, Fan ST, Lai EC, Wong J. Prospective randomized study of early versus delayed laparoscopic cholecystectomy for
acute cholecystitis. Ann Surg. 1998;227:461-7. (PMID: 9563529)
76. Lai PB, Kwong KH, Leung KL, Kwok SP, Chan AC, Chung SC, et al. Randomized trial of early versus delayed laparoscopic
cholecystectomy for acute cholecystitis. Br J Surg. 1998;85:764-7. (PMID: 9667702)
77. Chang L, Moonka R, Stelzner M. Percutaneous cholecystostomy for acute cholecystitis in veteran patients. Am J Surg.
2000;180:198-202. (PMID: 11084129)
78. Lai EC, Mok FP, Tan ES, Lo CM, Fan ST, You KT, Wong J. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med.
1992;326:1582-6. (PMID: 1584258)
79. Leung JW, Chung SC, Sung JJ, Banez VP, Li AK. Urgent endoscopic drainage for acute suppurative cholangitis. Lancet.
1989;1:1307-9. (PMID: 2566834)
80. Ke ZW, Zheng CZ, Li JH, Yin K, Hua JD. Prospective evaluation of magnetic resonance cholangiography in patients with
suspected common bile duct stones before laparoscopic cholecystectomy. Hepatobiliary Pancreat Dis Int. 2003;2:576-80.
(PMID: 14627523)
81. Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll
Surg. 1995;180:101-25. (PMID: 8000648)
82. Mahatharadol V. Bile duct injuries during laparoscopic cholecystectomy: an audit of 1522 cases. Hepatogastroenterology.
2004;51:12-4. (PMID: 15011821)
83. Werbel GB, Nahrwold DL, Joehl RJ, Vogelzang RL, Rege RV. Percutaneous cholecystostomy in the diagnosis and treatment of
acute cholecystitis in the high-risk patient. Arch Surg. 1989;124:782-5. (PMID: 2742479)
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 22 of 32
Acute Cholecystitis
Top
Glossary
ALT
alanine aminotransferase
AST
aspartate aminotransferase
CBC
complete blood count
CDCA
chenodeoxycholic acid
CI
confidence interval
CT
computed tomography
DISIDA
diisopropyl phenyl carboxymethyl iminodiacetic acid
ERCP
endoscopic retrograde cholangiopancreatography
GI
gastrointestinal
HIDA
hepato-iminodiacetic acid
ICU
intensive care unit
IgG
immunoglobulin G
IgM
immunoglobulin M
iv
intravenous
LFT
liver function test
MRC
magnetic resonance cholangiography
MRCP
magnetic resonance cholangiopancreatography
NSAID
nonsteroidal anti-inflammatory drug
RR
risk ratio
SD
standard deviation
TPN
total parenteral nutrition
UDCA
ursodeoxycholic acid
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 23 of 32
Acute Cholecystitis
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 24 of 32
Acute Cholecystitis
Top
Tables
Laboratory and Other Studies for Acute Cholecystitis
Test
Notes
Complete blood count
Look for leukocytosis
Liver function tests
Can be elevated in acute cholecystitis
Serum bilirubin
If >4 mg/dL, consider common bile-duct stones or Mirizzi's syndrome
Serum amylase
If significant increases (more than three times the upper limit of normal), consider pancreatitis or
common bile-duct stones (33)
Serum alkaline phosphatase
Elevation significantly predicts acute cholecystitis (25)
Right upper quadrant ultrasound scan
Sensitivity 81-98%
Specificity 70-98%
Portable, inexpensive.
Sonographic Murphy's sign (showing maximal tenderness directly over the visualized gallbladder) is
over 90% predictive of acute cholecystitis
HIDA scan
Sensitivity 85-97%
Specificity 90%
CT scan
Expensive; most useful to diagnose such complications as perforation
MRI scan or MRCP scan
Sensitivity 100% for cystic-duct obstruction; 69 for gallbladder-wall thickening
Specificity 93% for cystic-duct obstruction; 83% for gallbladder-wall thickening
Commonly used to diagnose ductal obstruction caused by stones or a malignant lesion
CT = computed tomography; HIDA = hepato-iminodiacetic acid; MRCP = magnetic resonance cholangiopancreatography; MRI = magnetic resonance imaging.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 25 of 32
Acute Cholecystitis
Differential Diagnosis of Acute Cholecystitis
Disease
Characteristics
Acute cholecystitis
Mid-epigastric pain progressing to right upper quadrant. Pain may also radiate to right scapula, right
shoulder, back, or lower abdomen. Murphy's sign is highly specific and predictive
Bilirubin >4 mg/dL is not a feature of uncomplicated acute cholecystitis
Acute cholangitis
Charcot triad (right upper quadrant pain, fever, jaundice)
or
Reynold pentad (Charcot triad and shock and mental-status changes)
Bilirubin generally >4 mg/dL.
AST and ALT levels may exceed 1000 U/L
Acute appendicitis
Mid-epigastric pain radiating to right lower quadrant
Can mimic acute cholecystitis, especially with a high-lying cecum
Acute pancreatitis
Mid-epigastric pain radiating to the back, nausea, vomiting, elevated amylase and lipase
Vomiting and hyperamylasemia are generally more pronounced than in acute cholecystitis
Pyelonephritis (right)
Costovertebral angle tenderness, evidence of urinary infection
Urinalysis helps establish the diagnosis
Peptic ulcer disease
Right upper quadrant or mid-epigastric pain
Perforated ulcer can mimic acute cholecystitis
Pulmonary/pleural disease
Cough, shortness of breath, chest or upper abdominal pain
Pleuritic pain component much less common in acute cholecystitis
Acute viral hepatitis
Prodromal syndrome, jaundice, AST and ALT levels generally >1000 U/L
LFT and bilirubin level usually much higher than in acute cholecystitis
Acute alcoholic hepatitis
Right upper quadrant pain, fever, jaundice, coagulopathy, leukocytosis, AST level usually two to three
times greater than ALT level
Bilirubin level generally >4 mg/dL
Recent significant alcohol intake
Inferior myocardial infarction
Chest/mid-epigastric pain, diaphoresis, shortness of breath, elevated cardiac enzymes, acutely
abnormal electrocardiogram
Presence of cardiac risk factors.
Pain characteristics generally different than acute cholecystitis
Mesenteric ischemia
Periumbilical or mid-epigastric pain out of proportion to tenderness
Fitz-Hugh-Curtis syndrome (gonococcal perihepatitis)
Right upper quadrant pain, adnexal tenderness, leukocytosis
Cervical smear shows gonococci
Hepatic abscess or tumor
Right upper quadrant pain, fever
Probably requires imaging studies to differentiate
Pre- and post-herpetic neuralgia
Right upper quadrant pain, fever, and malaise followed by vesicular rash on the thoracic dermatome
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 26 of 32
Acute Cholecystitis
Varicella IgM and IgG antibody assays helpful
Bleeding or infection of hepatic hydatid cysts
Right upper quadrant pain and fever
Ultrasound or CT scans confirm the diagnosis (34)
Gall bladder ascariasis
Right upper quadrant pain and fever
Ultrasound or MRC confirms the diagnosis (35)
Benign liver adenomas
Right upper quadrant pain
Ultrasound, CT scans, and biopsy confirm the diagnosis (36)
Torsion of the gallbladder
Right upper quadrant pain and fever
Ultrasound or CT scans confirm the diagnosis (37)
Bleeding within the gallbladder
Right upper quadrant pain
Ultrasound or CT scans confirm the diagnosis (38)
ALT = alanine aminotransferase; AST = aspartate aminotransferase; CT = computed tomography; IgG = immunoglobulin G; IgM = immunoglobulin M; LFT = liver function test; MRC = magnetic resonance
cholangiography.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 27 of 32
Acute Cholecystitis
Drug Treatment for Acute Cholecystitis
Drug or Drug Class
Dosing
Penicillins
Piperacillin/tazobactam (Zosyn)
3.375 g iv q6hr
Ampicillin/sulbactam (Unasyn)
3 g iv q6hr
Ticarcillin/clavulanate (Timentin)
3.1 g iv q6hr
Ampicillin
2 g iv q6hr
Side Effects
Precautions
Hypersensitivity reactions, hematologic
toxicity, vomiting, diarrhea
Seizures can occur when large doses
given with renal impairment
Constipation, hypokalemia, headache
If CrCl<40, decrease dose to 2.25 g iv
q6-8hr
Clinical Use
If CrCl<30, extend dosing interval
Nephrotoxicity
If <60 kg or CrCl<60, decrease dose.
Monitor electrolytes
If CrCl<50, extend dosing interval
Combine with gentamicin and
metronidazole
Other antibiotics
Ceftazidime (Fortaz, Tazicef)
1 g iv q8hr
Hypersensitivity reactions, hematologic
toxicity, hepatotoxicity, vomiting,
diarrhea
If CrCl<50, decrease dose
Combine with metronidazole
Metronidazole (Flagyl, Metro)
500 mg iv q6hr
Vomiting, diarrhea, anorexia,
headache, dizziness
Carcinogenicity. Avoid with
pregnancy. Avoid alcohol. Decrease
dose by 50% with severe hepatic
disease. Caution with: CKD, warfarin
Used in combination therapy
Gentamicin
3-5 mg/kg total daily dose, dosed q8hr
Vomiting, hepatotoxicity
Neurotoxicity, ototoxicity,
nephrotoxicity, neuromuscular
blockade, respiratory paralysis. Use
serum levels to guide dosing. Avoid
with pregnancy. Caution with severe
hepatic disease. Decrease dose with
CKD
Used in combination therapy
1 g iv q8hr
Vomiting diarrhea, constipation,
headache
Caution with seizure disorder. If
CrCl<50, decrease dose
Meropenem (Merrem)
= black box warning; bid = twice daily; CKD = chronic kidney disease; CNS = central nervous system; CrCl = creatinine clearance; GI = gastrointestinal; IM = intramuscular; iv = intravenous; PO = oral;
q6hr = every 6 hours; qd = once daily; qid = four times daily; SC = subcutaneous; tid = three times daily.
PIER provides key prescribing information for practitioners but is not intended to be a source of comprehensive drug information.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 28 of 32
Acute Cholecystitis
Top
Figures
Gallbladder Ultrasound Showing Gallstones
On ultrasonography, gallstones appear as an echogenic focus that casts an acoustic shadow.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 29 of 32
Acute Cholecystitis
Acalculous Cholecystitis
Gallbladder ultrasound consistent with acalculous cholecystitis showing an absence of gallstones or sludge, thickened gallbladder wall, and pericholecystic fluid.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 30 of 32
Acute Cholecystitis
Normal Gallbladder Ultrasound
An ultrasound of a normal gallbladder. The gallbladder wall is denoted by a thin white line. The gallbladder is filled with fluid and appears black.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 31 of 32
Acute Cholecystitis
Gallstone Ileus
Plain film of the abdomen showing air in the hepatic biliary tree (arrow) and dilated loops of bowel. Air in the biliary tree and signs of bowel obstruction support the diagnosis of fistula
between the biliary tree and bowel, most likely created by a gallstone that obstructed the cystic duct, eroded through the wall, and is now obstructing the small bowel.
PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA.
Page 32 of 32