Home Intra-abdominal infections Acute calculous cholecystitis

Acute calculous cholecystitis

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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)