Cholecystitis :Introduction
Background
Cholecystitis is defined as inflammation of the gallbladder
that occurs most commonly because of an obstruction of the
cystic duct from cholelithiasis. Ninety percent of cases
involve stones in the cystic duct (ie, calculous cholecystitis),
with the other 10% of cases representing acalculous
cholecystitis.1 Although bile cultures are positive for bacteria
in 50-75% of cases, bacterial proliferation may be a result
of cholecystitis and not the precipitating factor. Risk factors
for cholecystitis mirror those for cholelithiasis and include
increasing age, female sex, certain ethnic groups, obesity or
rapid weight loss, drugs, and pregnancy.
Acalculous cholecystitis is related to conditions associated
with biliary stasis, including debilitation, major surgery,
severe trauma, sepsis, long-term total parenteral nutrition
(TPN), and prolonged fasting. Other causes of acalculous
cholecystitis
include
cardiac
events;
sickle
cell
disease; Salmonella infections; diabetes mellitus; and
cytomegalovirus, cryptosporidiosis, or microsporidiosis
infections in patients with AIDS.
Pathophysiology
Acute calculous cholecystitis is caused by obstruction of the
cystic duct, leading to distention of the gallbladder. As the
gallbladder becomes distended, blood flow and lymphatic
drainage are compromised, leading to mucosal ischemia and
necrosis. A study by Cullen et al demonstrated the ability of
endotoxin to cause necrosis, hemorrhage, areas of fibrin
deposition, and extensive mucosal loss, consistent with an
acute ischemic insult.2Endotoxin also abolished the
contractile response to cholecystokinin (CCK), leading to
gallbladder stasis.
Although the exact mechanism of acalculous cholecystitis is
unclear, a couple of theories exist. Injury may be the result of
retained concentrated bile, an extremely noxious substance.
In the presence of prolonged fasting, the gallbladder never
receives a CCK stimulus to empty; thus, the concentrated bile
remains stagnant in the lumen.
Frequency
International
Cholelithiasis, the major risk factor for cholecystitis, has an
increased prevalence among people of Scandinavian descent,
Pima Indians, and Hispanic populations, whereas
cholelithiasis is less common among individuals from subSaharan Africa and Asia.3,4
Mortality/Morbidity
 Most patients with acute cholecystitis have a complete
remission within 1-4 days. However, 25-30% of patients
either require surgery or develop some complication.
 Patients with acalculous cholecystitis have a mortality
rate ranging from 10-50%, which far exceeds the
expected 4% mortality rate observed in patients with
calculous cholecystitis. Emphysematous cholecystitis has
a mortality rate approaching 15%.
 Perforation occurs in 10-15% of cases.
Race
 Populations at the lowest risk reside in sub-Saharan
Africa and Asia.
 In the United States, white people have a higher
prevalence than black people.
Sex
 Gallstones are 2-3 times more frequent in females than
in males, resulting in a higher incidence of calculous
cholecystitis in females.
 Elevated progesterone levels during pregnancy may
cause biliary stasis, resulting in higher rates of
gallbladder disease in pregnant females.
 Acalculous cholecystitis is observed more often in elderly
men.
Age
The incidence of cholecystitis increases with age. The
physiologic explanation for the increasing incidence of
gallstone disease in the elderly population is unclear. The
increased incidence in elderly men has been linked to
changing androgen-to-estrogen ratios.
Clinical
History
1. The most common presenting symptom of acute
cholecystitis is upper abdominal pain, often radiating to
the tip of the right scapula.
 Most patients with acute cholecystitis describe a history
of biliary pain. Some patients may have documented
gallstones. Acalculous biliary colic also occurs, most
commonly in young–to–middle-aged females. The
presentation is almost identical to calculous biliary colic
with the exception of reference range laboratory values
and no findings of cholelithiasis on ultrasound.
 Frequently, the pain begins in the epigastric region and
then localizes to the right upper quadrant (RUQ).
Although the pain may initially be described as colicky, it
becomes constant in virtually all cases.
 Signs of peritoneal irritation may be present, and, in
some patients, the pain may radiate to the right shoulder
or scapula.
2. Nausea and vomiting are generally present, and patients
may report fever.
3. In elderly patients, pain and fever may be absent, and
localized tenderness may be the only presenting sign.
Patients with acalculous cholecystitis may present
similarly to patients with calculous cholecystitis, but
acalculous cholecystitis frequently occurs suddenly in
severely ill patients without a prior history of biliary colic.
Often, patients with acalculous cholecystitis may present
with fever and sepsis alone, without history or physical
examination findings consistent with acute cholecystitis.
4. Cholecystitis is differentiated from biliary colic by the
persistence of constant severe pain for more than 6
hours.
Physical
1. Physical examination may reveal fever, tachycardia, and
tenderness in the RUQ or epigastric region, often with
guarding or rebound.
2. A palpable gallbladder or fullness of the RUQ is present
in 30-40% of cases.
3. Jaundice may be noted in approximately 15% of patients.
4. The absence of physical findings does not rule out the
diagnosis of cholecystitis. Many patients present with
diffuse epigastric pain without localization to the RUQ.
Patients with chronic cholecystitis frequently do not
have a palpable RUQ mass secondary to fibrosis involving
the gallbladder.
5. Elderly patients and patients with diabetes frequently
have atypical presentations, including absence of fever
and localized tenderness with only vague symptoms.
6. Murphy sign, which is specific but not sensitive for
cholecystitis, is described as tenderness and an
inspiratory pause elicited during palpation of the RUQ.
Causes
1. Risk factors for calculous cholecystitis mirror those for
cholelithiasis and include the following:
o Female sex
o Certain ethnic groups (see Race)
o Obesity or rapid weight loss
o Drugs (especially hormonal therapy in women)
o Pregnancy
o Increasing age
2. Acalculous cholecystitis is related to conditions
associated with biliary stasis, to include the following:
o Critical illness
o Major surgery or severe trauma/burns
o Sepsis
o Long-term TPN
o Prolonged fasting
3. Other causes of acalculous cholecystitis include the
following:
 Cardiac events, including myocardial infarction
 Sickle cell disease
 Salmonella infections
 Diabetes mellitus
 Patients
with
AIDS
with
cytomegalovirus,
cryptosporidiosis, or microsporidiosis
4. Idiopathic cases exist.
Differential Diagnoses
Abdominal Aortic Aneurysm Gastroesophageal Reflux Disease
Acute Mesenteric Ischemia Gastritis, Acute
Amebic Hepatic Abscesses
Hepatitis, Viral
Appendicitis
Myocardial Infarction
Biliary Colic
Nephrolithiasis
Biliary Disease
Pancreatitis, Acute
Cholangiocarcinoma
Peptic Ulcer Disease
Cholangitis
Pneumonia, Bacterial
Choledocholithiasis
Pregnancy and Urolithiasis
Cholelithiasis
Pyelonephritis, Acute
Gallbladder Cancer
Renal Disease and Pregnancy
Gallbladder Mucocele
Renal Vein Thrombosis
Gallbladder Tumors
Gastric Ulcers
Workup
Laboratory Studies
1. A retrospective study by Singer attempted to determine
a set of clinical and laboratory parameters that could be
used to predict the outcome of hepatobiliary
scintigraphy (HBS) in all patients with suspected acute
cholecystitis.5
 The results of the study showed that, in 40 patients with
pathologically confirmed acute cholecystitis, fever and
leukocytosis were absent at the time of presentation in
36 (90%) and 16 (40%) of the patients, respectively.
 The study also found that no combination of laboratory
or clinical values was useful in identifying patients at high
risk for a positive HBS finding.
2. Although laboratory criteria are not reliable in identifying
all patients with cholecystitis, the following findings may
be useful in arriving at the diagnosis:
 Leukocytosis with a left shift may be observed in
cholecystitis.
 Alanine aminotransferase (ALT) and aspartate
aminotransferase (AST) levels are used to evaluate the
presence of hepatitis and may be elevated in
cholecystitis or with common bile duct obstruction.
 Bilirubin and alkaline phosphatase assays are used to
evaluate evidence of common duct obstruction.
 Amylase/lipase assays are used to evaluate the presence
of pancreatitis. Amylase may also be elevated mildly in
cholecystitis.
 An elevated alkaline phosphatase level is observed in
25% of patients with cholecystitis.
 Urinalysis is used to rule out pyelonephritis and renal
calculi.
 All females of childbearing age should have pregnancy
testing.
Imaging Studies
1. Radiography (without contrast)
 Gallstones may be visualized in 10-15% of cases. This
finding only indicates cholelithiasis, with or without
active cholecystitis.
 Subdiaphragmatic free air cannot originate in the biliary
tract, and, if present, it indicates another disease
process.
 Gas limited to the gallbladder wall or lumen
represents emphysematous
cholecystitis,
usually
because of gas-forming bacteria, such as Escherichia
coli and clostridial and anaerobic streptococci species.
Emphysematous cholecystitis is associated with an


2.



3.



4.


increased mortality rate and occurs most commonly in
males with diabetes and with acalculous cholecystitis.
A diffusely calcified gallbladder (ie, porcelainized) most
commonly is associated with carcinoma, although one
retrospective study by Towfigh found no association
between partial calcification of the gallbladder and
carcinoma.6
Other findings may include renal calculi, intestinal
obstruction, or pneumonia.
Ultrasonography
Ultrasonography provides greater than 95% sensitivity
and specificity for the diagnosis of gallstones more than
2 mm in diameter. Ultrasonography is 90-95% sensitive
for cholecystitis and is 78-80% specific. Studies indicate
that emergency clinicians require minimal training in
order to use right upper quadrant ultrasonography in
their practice.
Ultrasonographic findings that are suggestive of acute
cholecystitis include the following: pericholecystic fluid,
gallbladder wall thickening greater than 4 mm, and
sonographic Murphy sign. The presence of gallstones
also helps to confirm the diagnosis.
Ultrasonography is performed best following a fast of at
least 8 hours because gallstones are visualized best in a
distended bile-filled gallbladder.
Hepatobiliary scintigraphy (hepatoiminodiacetic acid
[HIDA]/diisopropyl iminodiacetic acid [DISIDA])
HBS has been found to be up to 95% accurate in
diagnosing acute cholecystitis. The reported sensitivities
and specificities of biliary scintigraphy are in the range of
90-100% and 85-95%. (See the following 2 images.)
In a typical study, the gallbladder, common bile duct, and
small bowel fill within 30-45 minutes.
If the gallbladder is not visualized, intravenous morphine
administration can improve the accuracy of HBS by
increasing resistance to flow through the sphincter of
Oddi, resulting in filling of the gallbladder if the cystic
duct is patent. The addition of morphine also reduces
the number of false-positive scan results observed in
patients who are critically ill and immobilized with
viscous bile.
CT scan and MRI
The sensitivity and specificity of CT scan and MRI for
predicting acute cholecystitis have been reported to be
greater than 95%.7 Spiral CT scan and MRI (unlike
endoscopic
retrograde
cholangiopancreatography
[ERCP]) have the advantage of being noninvasive, but
they have no therapeutic potential and are most
appropriate in cases where stones are unlikely.
Findings suggestive of cholecystitis include wall
thickening (>4 mm), pericholecystic fluid, subserosal
edema (in the absence of ascites), intramural gas, and
sloughed mucosa.

CT scan and MRI are also useful for viewing surrounding
structures if the diagnosis is uncertain.
Procedures
1. Endoscopic retrograde cholangiopancreatography
 ERCP may be useful in patients at high risk for common
duct gallstones if signs of common bile duct obstruction
are present.
 A study performed by Sahai et al found that ERCP was
preferred over endoscopic ultrasound and intraoperative
cholangiography for patients at high risk for common
duct stones undergoing laparoscopic cholecystectomy.8
 ERCP allows visualization of the anatomy and may be
therapeutic by removing stones from the common bile
duct.
 Disadvantages include the need for a skilled operator,
high cost, and complications such as pancreatitis, which
occurs in 3-5% of cases.
2. Endoscopic
ultrasound-guided
transmural
cholecystostomy: Studies indicate that this procedure
may be safe as initial, interim, or definitive treatment of
patients with severe acute cholecystitis who are at high
operative risk for immediate cholecystectomy.9
3. Mutignani et al investigated the efficacy of endoscopic
gallbladder drainage as a treatment for acute
cholecystitis.10 The authors, who conducted the study on
35 patients with the condition and with no residual
common bile duct obstruction, found that endoscopic
gallbladder drainage was technically successful in 29
patients and, after a median period of 3 days, clinically
successful in 24 of them. Four patients died within 3 days
after the procedure as a result of septic complications,
while a fifth patient accidentally removed a
nasocholecystic drain 24 hours after the operation. At
follow-up (on 21 patients, after a median period of 17
months), the investigators found that 4 patients had
suffered a relapse of either acute cholecystitis (2
patients) or biliary pain (2 patients). Mutignani et al
concluded that endoscopic gallbladder drainage appears
to be an effective, but temporary, means of resolving
acute cholecystitis.
Histologic Findings
Edema and venous congestion are early acute changes. Acute
cholecystitis is usually superimposed on a histologic picture
of chronic cholecystitis. Specific findings include fibrosis,
flattening of the mucosa, and chronic inflammatory cells.
Mucosal herniations known as Rokitansky-Aschoff sinuses are
related to increased hydrostatic pressure and are present in
56% of cases. Focal necrosis and an influx of neutrophils may
also be present. Advanced cases may show gangrene or
perforation.
Treatment
Medical Care
For acute cholecystitis, initial treatment includes bowel rest,
intravenous hydration, analgesia, and intravenous antibiotics.
For mild cases of acute cholecystitis, antibiotic therapy with a
single broad-spectrum antibiotic is adequate. Some options
include the following:
1. The current Sanford guide recommendations include
piperacillin/tazobactam (Zosyn, 3.375 g IV q6h or 4.5 g IV
q8h), ampicillin/sulbactam (Unasyn, 3 g IV q6h), or
meropenem (Merrem, 1 g IV q8h). In severe lifethreatening cases, the Sanford Guide recommends
imipenem (500 mg IV q6h).
2. Alternative regimens include a third-generation
cephalosporin plus Flagyl (1 g IV loading dose followed
by 500 mg IV q6h).
3. Bacteria that are commonly associated with cholecystitis
include E coli and Bacteroides fragilis and Klebsiella,
Enterococcus, and Pseudomonas species.
4. Emesis can be treated with antiemetics and nasogastric
suction.
5. Because of the rapid progression of acute acalculous
cholecystitis to gangrene and perforation, early
recognition and intervention are required.
6. Supportive medical care should include restoration of
hemodynamic stability and antibiotic coverage for gramnegative enteric flora and anaerobes if biliary tract
infection is suspected.
7. Daily stimulation of gallbladder contraction with
intravenous CCK has been shown by some to effectively
prevent the formation of gallbladder sludge in patients
receiving TPN.
Surgical Care
Laparoscopic cholecystectomy is the standard of care for the
surgical treatment of cholecystitis. Studies have indicated
that early laparoscopic cholecystectomy resulted in shorter
total hospital stays with no significant difference in
conversion rates or complications.11 Wilson et al used
decision tree analytic modeling to compare the costeffectiveness and quality-adjusted life years (QALYs) of early
laparoscopic cholecystectomy (ELC) and delayed laparoscopic
cholecystectomy (DLC) and found that, on average, ELC is less
expensive and results in better quality of life (+0.05 QALYs
per
patient)
than
DLC.12
For elective laparoscopic cholecystectomy, the rate of
conversion from a laparoscopic procedure to an open surgical
procedure is approximately 5%. The conversion rate for
emergency cholecystectomy where perforation or gangrene
is
present
may
be
as
high
as
30%.
Some considerations regarding cholecystectomy include the
following:
1. Immediate cholecystectomy or cholecystotomy is usually
reserved for complicated cases in which the patient has
gangrene or perforation.
2. Early operation within 72 hours of admission has both
medical and socioeconomic benefits and is the preferred
approach for patients treated by surgeons with adequate
experience in laparoscopic cholecystectomy.13
3. For patients at high surgical risk, placement of a
sonographically guided, percutaneous, transhepatic
cholecystostomy drainage tube coupled with the
administration of antibiotics may provide definitive
therapy.14
4. Results of studies suggest that most patients with acute
acalculous cholecystitis can be treated with
percutaneous drainage alone.10
5. Contraindications for laparoscopic cholecystectomy
include the following:
 High risk for general anesthesia
 Morbid obesity
 Signs of gallbladder perforation, such as abscess,
peritonitis, or fistula
 Giant gallstones or suspected malignancy
 End-stage liver disease with portal hypertension and
severe coagulopathy
Consultations
Definitive therapy involves cholecystectomy or placement of
a drainage device; therefore, consultation with a surgeon is
warranted.
Consultation with a gastroenterologist for consideration of
ERCP may also be appropriate if concern exists
of choledocholithiasis.
Diet
Patients admitted for cholecystitis should receive nothing by
mouth (NPO) because of expectant surgery. However, in
uncomplicated cholecystitis, a liquid or low-fat diet may be
appropriate until the time of surgery.
Medication
The goals of pharmacotherapy are to reduce morbidity and
to prevent complications.
Antiemetics
Patients with cholecystitis frequently experience associated
nausea and vomiting. Antiemetics can help to make the
patient more comfortable and can prevent fluid and
electrolyte abnormalities.
Promethazine (Phenergan, Prorex, Anergan)
For symptomatic treatment of nausea in vestibular
dysfunction. Antidopaminergic agent effective in treating
emesis. Blocks postsynaptic mesolimbic dopaminergic
receptors in brain and reduces stimuli to brainstem reticular
system.
Adult: 12.5-25 mg PO/IV/IM/PR q4h prn
Pediatric: <2 years: Contraindicated
>2 years: 0.25-1 mg/kg PO/IV/IM/PR q4-6h prn
Prochlorperazine (Compazine)
May relieve nausea and vomiting by blocking postsynaptic
mesolimbic dopamine receptors through anticholinergic
effects and depressing reticular activating system. In addition
to antiemetic effects, it has the advantage of augmenting
hypoxic ventilatory response, acting as a respiratory
stimulant at high altitude.
Adult: 5-10 mg PO/IM tid/qid; not to exceed 40 mg/d
2.5-10 mg IV q3-4h prn; not to exceed 10 mg/dose or 40
mg/d 25 mg PR bid
Pediatric: 2.5 mg PO/PR q8h or 5 mg q12h prn; not to exceed
15 mg/d IV dosing is not recommended for children 0.1-0.15
mg/kg/dose IM; change to PO as soon as possible
Analgesics
Pain is a prominent feature of cholecystitis. Classic teaching is
that morphine is not the agent of choice because of the
possibility of increasing tone at the sphincter of Oddi.
Meperidine has been shown to provide adequate analgesia
without affecting the sphincter of Oddi and, therefore, is the
DOC.
Meperidine (Demerol)
DOC. Analgesic with multiple actions similar to those of
morphine. May produce less constipation, smooth muscle
spasm, and depression of cough reflex than similar analgesic
doses of morphine.
Adult: 50-150 mg PO/IV/IM/SC q3-4h prn
Pediatric: 1-1.8 mg/kg (0.5-0.8 mg/lb) PO/IV/IM/SC q3-4h
prn; not to exceed adult dose
Hydrocodone and acetaminophen (Vicodin, Lortab 5/500,
Lorcet-HD)
Drug combination indicated for moderate to severe pain.
Each tab/cap contains 5 mg hydrocodone and 500 mg
acetaminophen.
Adult: 1-2 tab/cap PO q4-6h prn
Pediatric: <12 years: 10-15 mg/kg/dose acetaminophen PO
q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10
mg hydrocodone bitartrate/dose or 5 doses/24 h
Oxycodone and acetaminophen (Percocet, Tylox, Roxicet)
Drug combination indicated for relief of moderate to severe
pain.
Each tab/cap contains 5 mg oxycodone and 325 mg
acetaminophen.
Adult: 1-2 tab/cap PO q4-6h prn
Pediatric: 0.05-0.15 mg/kg/dose oxycodone PO; not to
exceed 5 mg/dose of oxycodone PO q4-6h prn
Antibiotics
Treatment of cholecystitis with antibiotics should provide
coverage against the most common organisms, includingE
coli, B.fragilis, and Klebsiella, Pseudomonas, and Enterococcu
s species. Current Sanford guide recommendations for the
treatment of cholecystitis include Unasyn, Zosyn for non–lifethreatening cases of cholecystitis. In life-threatening cases,
Sanford recommends Primaxin or meropenem. Alternatives
include metronidazole plus a third-generation cephalosporin
or Cipro or Aztreonam.
Ciprofloxacin (Cipro)
Fluoroquinolone that inhibits bacterial DNA synthesis and,
consequently, growth, by inhibiting DNA gyrase and
topoisomerases, which are required for replication,
transcription, and translation of genetic material. Quinolones
have broad activity against gram-positive and gram-negative
aerobic organisms. Has no activity against anaerobes.
Continue treatment for at least 2 d (7-14 d typical) after signs
and symptoms have disappeared.
Adult: 400 mg IV q12h
Pediatric:
<18
years:
Not
recommended
>18 years: Administer as in adults
Meropenem (Merrem)
Bactericidal broad-spectrum carbapenem antibiotic that
inhibits cell-wall synthesis. Effective against most grampositive and gram-negative bacteria.
Has slightly increased activity against gram-negatives and
slightly decreased activity against
staphylococci and
streptococci compared to imipenem.
Adult: 1 g IV q8h
Pediatric: 60 mg/kg/d IV divided q8h
Imipenem and cilastatin (Primaxin)
For treatment of multiple organism infections in which other
agents do not have wide spectrum coverage or are
contraindicated due to potential for toxicity.
Adult: Base initial dose on severity of infection, and
administer in equally divided doses; dose may range from
250 to 500 mg q6h IV for a maximum of 3-4 g/d
Alternatively, 500-750 mg IM q12h or intra-abdominally
Pediatric: Infants >3 months and children <12 years: 15-25
mg/kg/dose IV q6h
Fully susceptible organisms: Not to exceed 2 g/d
Infections with moderately susceptible organisms: Not to
exceed 4 g/d >12 years: Administer as in adults
Piperacillin and tazobactam (Zosyn)
Antipseudomonal penicillin plus beta-lactamase inhibitor.
Inhibits biosynthesis of cell wall mucopeptide and is effective
during stage of active multiplication.
Adult: 3/0.375 g (piperacillin 3 g and tazobactam 0.375 g) IV
q6h
Pediatric: 75 mg/kg of piperacillin component IV q6h
Ampicillin and sulbactam (Unasyn)
Drug combination of beta-lactamase inhibitor with ampicillin.
Covers epidermal and enteric flora and anaerobes. Not ideal
for nosocomial pathogens.
Adult: 1.5 g (1 g ampicillin plus 0.5 g sulbactam) to 3 g (2 g
ampicillin plus 1 g sulbactam) IV/IM q6-8h; not to exceed 4
g/d sulbactam or 8 g/d ampicillin
Pediatric: <3 months: Not established
3 months to 12 years: 100-200 mg ampicillin/kg/d (150-300
mg Unasyn) IV divided q6h
>12 years: Administer as in adults
Metronidazole (Flagyl)
Imidazole ring-based antibiotic active against various
anaerobic bacteria and protozoa. Used in combination with
other antimicrobial agents (except Clostridium difficile
enterocolitis).
Adult: Loading dose: 15 mg/kg or 1 g for 70-kg adult IV 1 h
Maintenance dose: 6 h following loading dose, infuse 7.5
mg/kg or 500 mg for 70-kg adult over 1 h q6-8h; not to
exceed 4 g/d
Pediatric: Administer as in adults
Follow-up
Further Inpatient Care
Objectives during inpatient stay include the following:
 Correction of fluid and electrolyte abnormalities
 Antibiotics for complicating infections
 Performing imaging studies as appropriate (eg,
ultrasound, HBS)
 Cholecystectomy once the patient is stable or
percutaneous transhepatic cholecystostomy drainage in
unstable high-risk surgical patients
Further Outpatient Care
In cases of uncomplicated cholecystitis, outpatient treatment
may be appropriate. If a patient can be treated as an
outpatient, discharge with antibiotics, appropriate analgesics,
and definitive follow-up care. Criteria for outpatient
treatment include the following:
 Afebrile with stable vital signs
 No evidence of obstruction by laboratory values
 No evidence of common bile duct obstruction on
ultrasound
 No underlying medical problems, advanced age,
pregnancy, or immunocompromised condition
 Adequate analgesia
 Reliable patient with transportation and easy access to a
medical facility
 Prompt follow-up care
Inpatient & Outpatient Medications
For outpatient treatment of uncomplicated cholecystitis, the
following medicines may be appropriate:
 Prophylactic antibiotic coverage with Levaquin (500 mg
PO qd) and Flagyl (500 mg PO bid), which should provide
coverage against the most common organisms
 Antiemetics, such as oral/rectal Phenergan or
Compazine, to control nausea and to prevent fluid and
electrolyte disorders
 Analgesics, such as oral Percocet or Vicodin
Transfer
Consider patient transfer if the following conditions apply:
 Appropriate diagnostic resources are not available.
 Higher level of care is required.
 Surgeons and/or specialists are unavailable.
Deterrence/Prevention
1. Prevention of cholecystitis requires cholecystectomy.
2.
In patients who are unstable, percutaneous transhepatic
cholecystostomy drainage may be appropriate.
3. Some studies have shown that daily CCK administration
may help prevent acalculous cholecystitis in patients at
risk.
Complications
1. Bacterial proliferation within the obstructed gallbladder
results in empyema of the organ. Patients with
empyema may have a toxic reaction and may have more
marked fever and leukocytosis. The presence of
empyema frequently requires conversion from
laparoscopic to open cholecystectomy.
2. In rare instances, a large gallstone may erode through
the gallbladder wall into an adjacent viscus, usually the
duodenum. Subsequently, the stone may become
impacted in the terminal ileum or in the duodenal bulb
and/or pylorus, causing a gallstone ileus.
3. Emphysematous cholecystitis occurs in approximately
1% of cases and is noted by the presence of gas in the
gallbladder wall from the invasion of gas-producing
organisms,
such
as E
coli,
Clostridia
perfringens,and Klebsiella species. This complication is
more common in patients with diabetes, has a male
predominance, and is acalculous in 28% of cases.
Because of a high incidence of gangrene and perforation,
emergency cholecystectomy is recommended.
4. Sepsis
5. Pancreatitis
6. Perforation occurs in up to 15% of patients.
Prognosis
1. For uncomplicated cholecystitis, the prognosis is
excellent, with a very low mortality rate.
2. In patients who are critically ill with cholecystitis, the
mortality rate approaches 50-60%, especially in the
setting of gangrene or empyema.
3. Once complications such as perforation/gangrene
develop, the prognosis becomes less favorable. In
patients who are critically ill with acalculous cholecystitis
and perforation or gangrene, the mortality rate can be as
high as 50-60%.
Patient Education
1. Patients diagnosed with cholecystitis must be educated
regarding causes of their disease, complications if left
untreated, and medical/surgical options to treat
cholecystitis.
Miscellaneous
Medicolegal Pitfalls
Delays in making the diagnosis of acute cholecystitis result in
a higher incidence of morbidity and mortality. This is
especially true for ICU patients who develop acalculous
cholecystitis. The diagnosis should be considered and
investigated promptly in order to prevent poor outcomes.