DIAGNOSIS
Clinical signs and symptoms
- Abdominal pain in the upper right quadrant of the abdomen
- Elevated temperature
- Absence of vomiting
- Abdominal tenderness (sign of complicated acute diverticulitis)
Laboratory markers
- White blood cell
- Leucocyte shift to left (>75 %)
- C-reactive protein
Imaging
- US
- CT
- MRI
Imaging findings
- Pericholecystic fluid (fluid around the gall bladder)
- Distended gall bladder, oedematous gallbladder wall
- Gall stones
- Murphy’s sign can be elicited on ultrasound examination
Ultrasound is the investigation of choice in patients suspected of having acute cholecystitis. CT is usually indicated when sonography is non-diagnostic or patients have confusing signs and symptoms.
TREATMENT
Uncomplicated cholecystits
- – Early (within 7 days) laparoscopic/open cholecystectomy (Early treatment). Post-operative antibiotics are unnecessary if source control is adequate.
- – Antibiotic therapy for 5-7 days and planned delayed laparoscopic/open cholecystectomy (delayed treatment).
Early cholecystectomy is a safe treatment for acute cholecystitis and generally results in shorter recovery time and hospitalization compared to delayed cholecystectomies.
Complicated cholecystitis
- – Laparoscopic/open cholecystectomy and antibiotic therapy for 3-5 days
Patients who have ongoing signs of infection or systemic illness (ongoing infection) beyond 5 to 7 days of antibiotic treatment, should warrant a diagnostic investigation. - – Cholecystostomy may be a safe and effective treatment for acute cholecystitis in critically ill and/or with multiple comorbidities and unfit for surgery patients.
Empiric antibiotic regimens. Normal renal function
- One of following antibiotics
- Amoxicillin/clavulanate 1.2-2.2 g 8-hourly
- Piperacillin/Tazobactam 4.5 g 6-hourly (in critically ill patients)
- Ceftriaxone 2 g 24-hourly + Metronidazole 500 mg 6-hourly
- Cefotaxime 2g 8-hourly + Metronidazole 500 mg 6-hourly
- or
- In patients with beta-lactam allergy
- A fluoroquinolone-based regimen
- Ciprofloxacin 400 mg 8/12-hourly + Metronidazole 500 mg 6- hourly
- or
- In patients at high risk for infection with community-acquired ESBL-producing Enterobacteriaceae
- One of the following antibiotics
- Tigecycline* 100 mg LD, then 50 mg 12-hourly (Carbapenem-sparing strategy)
- Ertapenem 1 g 24-hourly
- Meropenem 1 g 8-hourly (only in patients with septic shock)
- Doripenem 500 mg 8-hourly (only in patients with septic shock)
- Imipenem/Cilastatin 500 mg 6-hourly (only in patients with septic shock)
