Ask AI

Search

Updates

Table of contents

Acute cholecystitis

What's new

Updated 2024 IDSA guidelines for diagnostic imaging and microbiological testing in acute cholecystitis.

Background

Overview

Definition
Acute cholecystitis is an inflammation of the gallbladder and is usually caused by obstruction of the cystic duct.
1
Pathophysiology
Acute cholecystitis is mostly caused by gall stones or by impacted biliary sludge with or without secondary bacterial infection (E. coli, Klebsiella, and Streptococcus faecalis).
2
Disease course
The inflammatory process due to obstruction of cystic duct results in acute cholecystitis, which causes clinical manifestations of persistent pain and tenderness in the RUQ, and mild jaundice. Disease progression may lead to gangrenous cholecystitis, gallbladder perforation, cholecystoenteric fistulas, gallstone ileus, and acalculous cholecystitis.
2
Prognosis and risk of recurrence
In the US, the overall mortality associated with untreated complications of acute cholecystitis is approximately 20%.
3

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute cholecystitis are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2024), the Infectious Diseases Society of America (IDSA 2024), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES 2024), the Danish Surgical Society (DSS 2022), the World Society of Emergency Surgery ...
Show more

Screening and diagnosis

Clinical presentation: as per AAFP 2024 guidelines, use the Murphy sign on physical examination to rule in acute cholecystitis.
B
Create free account

More topics in this section

  • Diagnostic criteria

Classification and risk stratification

Severity grading and prognosis: as per IDSA 2024 guidelines, assess disease severity for risk stratification in patients with complicated intra-abdominal infections. Consider using the APACHE II as the preferred severity of illness score for risk stratification within 24 hours of hospital or ICU admission in adult patients with complicated intra-abdominal infection, if a severity of illness score is used.
B
Create free account

More topics in this section

  • Risk stratification of choledocholithiasis

  • Risk stratification of elderly patients

Diagnostic investigations

General principles
As per WSES 2020 guidelines:
Consider using a combination of detailed history, complete clinical examination, laboratory tests, and imaging for the diagnosis of acute calculous cholecystitis, although recognize that the best combination is not known.
C
Do not rely on a single clinical or laboratory finding to confirm or exclude acute cholecystitis.
D
Create free account

More topics in this section

  • Abdominal ultrasound

  • Further imaging (general population)

  • Further imaging (elderly patients)

  • Laboratory tests (CBC and serum biochemistry)

  • Laboratory tests (blood cultures)

  • Evaluation for choledocholithiasis

Medical management

Indications for nonoperative management
As per WSES 2020 guidelines:
Consider offering nonoperative management with antibiotics and observation in patients with acute calculous cholecystitis refusing or not suitable for surgery.
C
Consider offering alternative treatment options (such as gallstone dissolution or extracorporeal shock wave lithotripsy) in patients with acute calculous cholecystitis who have failed nonoperative management and are still refusing or not suitable for surgery.
C
Create free account

More topics in this section

  • Antibiotic therapy (general population)

  • Antibiotic therapy (elderly patients)

  • NSAIDs

Perioperative care

Preoperative antibiotics: as per EASL 2016 guidelines, avoid administering routine antibiotic prophylaxis before elective laparoscopic cholecystectomy.
D
Create free account

More topics in this section

  • Postoperative antibiotics

Surgical interventions

Cholecystectomy, indications: as per DSS 2022 guidelines, consider performing acute laparoscopic cholecystectomy in favor of gallbladder drainage in high-risk patients with acute cholecystitis.
C
Create free account

More topics in this section

  • Cholecystectomy (timing)

  • Cholecystectomy (surgical approach)

  • Cholecystectomy (intraoperative bile and tissue cultures)

  • Cholecystectomy (management of postoperative leaks)

  • Gallbladder drainage (indications)

  • Gallbladder drainage (surgical technique)

  • Gallbladder drainage (timing for removal)

  • Intra-abdominal culture

  • Management of choledocholithiasis

Specific circumstances

Pregnant patients: as per IDSA 2024 guidelines, consider obtaining ultrasound or MRI as the initial diagnostic imaging in pregnant patients with suspected acute cholecystitis.
⁄
Create free account