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)
- White blood cell
- Leucocyte shift to left (>75 %)
- C-reactive protein
- 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.
– 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.
– 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
In patients with beta-lactam allergy
A fluoroquinolone-based regimen
Ciprofloxacin 400 mg 8/12-hourly + Metronidazole 500 mg 6- hourly
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)