MAKATI MEDICAL CENTER
Clinical Pathways
Department: Medicine – Gastroenterology
Subject: Acute Cholecystitis
Effective Date: February 11, 2008
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ACUTE CHOLECYSTITIS
OPERATIONAL DEFINITIONS
Symptomatic Cholecystitis
– includes both acute and chronic cholecystitis
Acute Cholecystitis
- acute upper abdominal pain with tenderness under the right costal margin
accompanied by fever, laboratory markers of inflammation and scintigraphic or
sonologic evidence
Complicated Cholecystitis
- refers to emphysematous cholecystitis, cholecystitis with perforation and secondary
peritonitis, pericholecystic abscess formation and generalized peritonitis
Early Cholecystectomy
-cholecystectomy performed within 72 hours of admission
Delayed Cholecystectomy
- initial conservative treatment with antimicrobials followed by cholecystectomy 8-12
weeks later
Standard Open Cholecystectomy
- transverse subcostal skin incision greater than 6 cm in length to provide comfortable
exposure of the gallbladder
Mini-incision/Minilaparotomy Cholecystectomy
- transverse subcostal skin incision less than or equal to 6 cm in length
Laparoscopic Cholecystectomy
- use of 10 mm subxiphoid and 5 mm lateral trocars for cholecystectomy
Each guideline is rated using a two-part rating system. Roman numerals I through III are
used to indicate the “quality of evidence” while the letters A through C are used to indicate
the “strength of the recommendation.”
MAKATI MEDICAL CENTER
Clinical Pathways
Department: Medicine – Gastroenterology
Subject: Acute Cholecystitis
Effective Date: February 11, 2008
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PRACTICE GUIDELINES
The clinical evidence was rated according to the assessment system of the Infectious Disease
Society of America:
Level I – Evidence from at least one properly designed randomized controlled
trial or meta-analysis
Level II – Evidence from at least one well-designed clinical trial without proper
randomization, from cohort or case-controlled analytic studies (preferably
from one center), from multiple time-series, or from dramatic results in
uncontrolled experiments
Level III – Evidence from opinions of respected authorities on the basis of clinical
The strength of recommendations for the guidelines was categorized according to the level
of agreement of the panel of experts after a votation of the participants:
Category A – Recommendations that were approved by consensus (at least 75 per
cent of the multi-sectoral expert panel)
Category B – Recommendations that were somewhat controversial and did not
meet consensus
Category C – Recommendations that caused real disagreements among the
members of the panel
DIAGNOSIS
No single clinical finding or combination of findings is sufficient to establish or
exclude the diagnosis of symptomatic cholecystitis. (LEVEL I EVIDENCE,
CATEGORY A RECOMMENDATION)
The most accurate imaging test in suspected acute cholecystitis is hepatobiliary
scintigraphy. (LEVEL I EVIDENCE) For practical purposes however, ultrasonography is
the appropriate initial imaging procedure. (LEVEL III EVIDENCE, CATEGORY A
RECOMMENDATION)
Ultrasound is the most helpful diagnostic test for chronic calculous cholecystitis.
MAKATI MEDICAL CENTER
Clinical Pathways
Department: Medicine – Gastroenterology
Subject: Acute Cholecystitis
Effective Date: February 11, 2008
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TREATMENT
Routine cholecystectomy is not recommended for asymptomatic gallstones. (LEVEL II
EVIDENCE, CATEGORY A RECOMMENDATION). However, cholecystectomy
may be considered in a selected group of patients. (LEVEL III EVIDENCE,
CATEGORY A RECOMMENDATION
A. ACUTE CHOLECYSTITIS
The recommended surgical approaches for acute cholecystitis are open cholecystectomy
(standard or mini-cholecystectomy) or laparoscopic cholecystectomy. (LEVEL I
EVIDENCE, CATEGORY A RECOMMENDATION)
Patients with acute cholecystitis should undergo cholecystectomy within 72 hours of
admission. (LEVEL I EVIDENCE, CATEGORY A RECOMMENDATION)
Empiric antibiotic therapy is recommended for patients with acute cholecystitis.
(LEVEL I EVIDENCE, CATEGORY A RECOMMENDATION)
The following antibiotics are recommended for therapy in uncomplicated acute
cholecystitis:
Cefazolin 1 gram IV every 8 hours
Cefuroxime 1.5 grams IV every 8 hours
Cefoxitin 2 grams IV every 8 hours (if at risk for anaerobic infection)
For patients with allergy to beta-lactam antibiotics:
Fluoroquinolone 400 mg IV every 12 hours +/- Metronidazole 500 mg IV every 6
hours LEVEL I EVIDENCE CATEGORY A RECOMMENDATION
The following antibiotics are recommended for therapy in complicated acute
cholecystitis:
Cefoxitin 2 grams IV every 8 hours
Ertapenem 1 gram IV every 24 hours
Beta-lactam/Beta-lactamase inhibitors:
Ampicillin-sulbactam 1.5-3 grams IV every 6 hours (add Gentamicin 240 mg IV
once a day if with risk for enterococcal infection)
For patients with allergy to beta-lactam antibiotics:
Fluoroquinolone 400 mg IV every 12 hours plus Metronidazole 500 mg IV every 6 hours
LEVEL I EVIDENCE CATEGORY A RECOMMENDATION
MAKATI MEDICAL CENTER
Clinical Pathways
Department: Medicine – Gastroenterology
Subject: Acute Cholecystitis
The duration of therapy may vary depending
operation. Therapy may be maintained for
Sequential therapy to oral antibiotics may
function has returned. (LEVEL I
RECOMMENDATION).
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on the clinician’s assessment after the
5 to 7 days for complicated cases.
be considered when gastrointestinal
EVIDENCE, CATEGORY A
The absence of fever for 24 hours ( temperature < 38 C), the ability to tolerate oral
intake and a normal WBC count with 3 per cent or less band forms are useful
parameters for the discontinuation of antibiotic therapy. (LEVEL II EVIDENCE,
CATEGORY A RECOMMENDATION)
B. CHRONIC CHOLECYSTITIS
Laparoscopic cholecystectomy is the recommended surgical approach in the
management of chronic cholecystitis. (LEVEL I EVIDENCE, CATEGORY A
RECOMMENDATION) Open cholecystectomy may be done on an individual
basis. (LEVEL III EVIDENCE, CATEGORY A RECOMMENDATION)
Antibiotic prophylaxis is recommended for patients who will undergo open
cholecystectomy for chronic cholecystitis. (LEVEL I EVIDENCE, CATEGORY
A RECOMMENDATION) For patients who will undergo laparoscopic
cholecystectomy, antibiotic prophylaxis is likewise recommended. (LEVEL III
EVIDENCE, CATEGORY A RECOMMENDATION)
The following antibiotics are recommended for prophylaxis in chronic cholecystitis:
Cefazolin 1 gram IV single dose within 2 hours pre-operatively
Alternative agents:
Cefuroxime 1.5 grams IV single dose within 2 hours pre-operatively
Gentamicin 80 mg IV single dose within 2 hours pre-operatively
LEVEL I EVIDENCE CATEGORY A RECOMMENDATION
An intra-peritoneal drain need not be routinely placed after cholecystectomy.
(LEVEL I EVIDENCE, CATEGORY A RECOMMENDATION)
REFERENCES
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less traumatic? Prospective randomized study comparing minisite and
MAKATI MEDICAL CENTER
Clinical Pathways
Department: Medicine – Gastroenterology
Subject: Acute Cholecystitis
conventional
laparoscopic
Dec;26(12):1437-1440.
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MAKATI MEDICAL CENTER
Clinical Pathways
Department: Medicine – Gastroenterology
Subject: Acute Cholecystitis
Effective Date: February 11, 2008
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12. Eldar S, Sabo E, Nash E, et al. Laparoscopic cholecystectomy for acute cholecystitis:
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