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Acute cholecystitis

Definition
Acute cholecystitis is an inflammation of the gallbladder and is usually caused by obstruction of the cystic duct.
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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).
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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.
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Prognosis and risk of recurrence
In the US, the overall mortality associated with untreated complications of acute cholecystitis is approximately 20%.
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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 Danish Surgical Society (DSS 2022), the World Society of Emergency Surgery (WSES 2020), the World Society of Emergency Surgery (WSES/SICG 2019), the Tokyo Guidelines (TG 2018), the European Association for the Study of the Liver (EASL 2016), and the American Society for Gastrointestinal Endoscopy (ASGE 2015).
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Guidelines

1.Screening and diagnosis

Clinical presentation: as per TG 2018 guidelines, recognize that severe (grade III) acute cholecystitis causes systemic symptoms because of organ damage and affects survival prognosis.
B
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  • Diagnostic criteria

2.Classification and risk stratification

Severity grading and prognosis: as per WSES 2020 guidelines, insufficient evidence to suggest the use of any prognostic model in patients with acute calculous cholecystitis.
I

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  • Risk stratification of choledocholithiasis

  • Risk stratification of elderly patients

3.Diagnostic investigations

General principles
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

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  • Abdominal ultrasound

  • Further imaging (general population)

  • Further imaging (elderly patients)

  • Laboratory tests

  • Evaluation for choledocholithiasis

4.Medical management

Indications for nonoperative management
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

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  • Antibiotic therapy (general population)

  • Antibiotic therapy (elderly patients)

5.Perioperative care

Preoperative antibiotics: avoid administering routine antibiotic prophylaxis before elective laparoscopic cholecystectomy.
D

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  • Postoperative antibiotics

6.Surgical interventions

Cholecystectomy, indications, DSS: consider performing acute laparoscopic cholecystectomy in favor of gallbladder drainage in high-risk patients with acute cholecystitis.
C

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  • 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)

  • Management of choledocholithiasis