6/28/2014 Johns Hopkins Guides: Cholecystitis

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Cholecystitis Content Manager
PATHOGENS

CLINICAL Christopher F. Carpenter, M.D.; Nick Gilpin, D.O.

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PATHOGENS
TREATMENT
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Acute cholecystitis Usually inflammatory and noninfectious.
If infectious, frequently polymicrobial. Leading pathogens: Print Page Print Topic
Surgical Treatment
Prophylaxis for E. coli
cholecystectomy Klebsiella species Related Content
Selected Drug C omments Enterobacter species Infectious Diseases and
Enterococcus Diabetes
FOLLOW UP
Pathogenicity is unclear for organisms cultured in bile/gall bladder unless C lostridium species
OTHER INFORMATION
also recovered in blood. Isospora belli
Pathogen Specific Therapy Anaerobes are less significant unless bile duct to bowel anastomosis or
C yclospora cayetanensis
Basis for recommendation fistula present; if so, the most common organisms include Clostridium and
Bacteroides species. Ertapenem
References Pathogenic role of enterococci and anaerobes are otherwise not well Meropenem
defined and empirical coverage not usually required.
Trovafloxacin

CLINICAL Piperacillin + Tazobactam

Ticarcillin + C lavulanic Acid

Gallstones occur in approximately 3-20% of the population worldwide, with
more than 80% asymptomatic. C ystoisospora belli
Acute cholecystitis: develops in 1-3% with symptomatic gallstones,
accounting for 3-9% of hospital admissions for acute abdominal pain.
more ...
~60% of patients with acute cholecystitis are women, but cholecystitis
tends to be more severe in men.
No single history, exam, or laboratory finding is sufficient for diagnosis;
combination of findings and clinical gestalt more likely to lead to
diagnosis with imaging study to confirm.
Most often caused by gallstones (>90%).
Acalculous cholecystitis (i.e., cholecystitis without gallstones) occurs
typically in otherwise critically ill or injured patients.
Acute cholecystitis is usually noninfectious.
The gallbladder wall may become necrotic (gangrenous cholecystitis), or
superinfection with anaerobic organisms may lead to gas in the wall or
lumen of the gallbladder (emphysematous cholecystitis).

DIAGNOSIS

Hx: nausea/vomiting and RUQ pain (biliary colic: often following fatty meal)
and may have fever.
Predisposition: female sex, multiparity, obesity, recent pregnancy, sickle
cell.
Diaphragmatic irritation may lead to right shoulder pain; pain may also
radiate to the back.
Majority of patients have gallbladder-associated symptoms prior to the
development of acute cholecystitis.
PE: Murphy’s sign (inspiratory arrest during deep palpation over the
gallbladder) not highly sensitive but quite specific.
Rebound and guarding are less commonly found and indicate peritonitis.
Hypoactive bowel sounds and a palpable mass in the RUQ may also be
present.
Jaundice/hyperbilirubinemia is unusual, but may suggest
choledocholithiasis or Mirrizzi’s syndrome (the stone in the cystic duct or
gallbladder neck causes compression of the common bile duct or common
hepatic duct).
Lab: elevated WBC, variable elevations of alkaline phosphatase, bilirubin
and transaminases; increased amylase may occasionally occur.
Imaging:
Abdominal ultrasound (US), initial imaging test of choice. Sensitivity
approaches 98% with a negative predictive value of 95%.
Hepatobiliary scintigraphy (HIDA scan) may reveal absence of gallbladder
filling that indicates cystic duct obstruction; sensitivity is about 80-90%
for acute cholecystitis.
HIDA is less specific in acalculous cholecystitis and ultrasonography plays
a larger role in diagnosis as does percutaneous cholecystostomy.
One review suggests that HIDA has a higher sensitivity (96%) with
similar specificity (90%) in comparison with US.
A suspected diagnosis includes local signs of inflammation (e.g., Murphy’s
sign or RUQ pain/tenderness) plus systemic signs of inflammation (e.g.,
elevated WBC count, fever, elevated CRP). A confirmed diagnosis includes

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6/28/2014 Johns Hopkins Guides: Cholecystitis
imaging findings consistent with cholecystitis.
The revised Tokyo Guidelines (TG13) have a high sensitivity and specificity
for acute cholecystitis (91% and 97%, respectively). Criteria:
Murphy’s sign and/or RUQ mass/pain/tenderness AND systemic findings
of inflammation (fever, leukocytosis, or elevated CRP).
Criteria for a definitive diagnosis include the criteria for a suspected
diagnosis AND imaging findings characteristic of acute cholecystitis.

TREATMENT
Acute cholecystitis
Acute cholecystitis is usually only an inflammatory process w/o infection;
however, patients should receive antimicrobial therapy initially.
Antimicrobials may then be discontinued within 24 hours if there is no
evidence of infection outside the gallbladder.
Early laparoscopic cholecystectomy is preferred treatment (see surgical
treatment below).
Persistent fever/SIRS or illness following cholecystectomy indicates
complication, and antimicrobial treatment should be extended accordingly.
Antibiotics:
Choice of antibiotic depends on whether community-acquired without
comorbidities or prior abx exposure
Community-acquired: cephalosporins, ticarcillin/clavulanate,
ertapenem, moxifloxacin.
Abx-experienced, recent GI surgeries, nosocomial setting or
comorbidities: piperacillin/tazobactam, meropenem, imipenem,
fluoroquinolone/metronidazole, cefepime or
ceftazidime/metronidazole.
Anaerobic and enterococcal coverage is generally not required unless in
severe infections.
Duration: limited to 4-7 days in conjunction with adequate source control
and clinical resolution of symptoms.
Mild-moderate:
Cefazolin 1-2g IV q8h
Cefuroxime 0.75-1.5g IV q8h
Ceftriaxone 1-2g IV q24h
Moxifloxacin 400mg IV daily
Ertapenem 1g IV qday
Severe/nosocomial/prior antibiotics:
Piperacillin/tazobactam 3.375g IV q6h or 4.5g IV q8h
Ticarcillin/clavulanate 3.1g IV q6h
Imipenem/cilastatin 250-500mg IV q6-8h
Meropenem 0.5-1g IV q8h
Doripenem 500mg IV q8h
Levofloxacin 500mg IV q24h or ciprofloxacin 400mg IV q12h PLUS
metronidazole 500mg IV q8h
Tigecycline100mg IV times one dose then 50mg IV q12h.
May be useful in patients with penicillin allergy; however increase
mortality risk associated with its use in comparison with other
antibiotics used to treat a variety of serious infections, including
intraabdominal infections, was identified via a pooled analysis of
clinical trials.

Surgical Treatment
Laparoscopic cholecystectomy preferred if possible.
Early cholecystectomy (soon after admission) should be considered in
the majority of cases; some surgeons still advocate delayed surgery.
Even in extreme elderly, safe and well tolerated, but may be associated
with a higher rate of conversion to open cholecystectomy, as well as
increased morbidity and a longer hospital stay.
Open cholecystectomy, if technically needed.
Percutaneous drainage or cholecystostomy if unable to tolerate operative
approaches.
Early/emergent intervention is indicated in acalculous cholecystitis due to
risk of gangrene and/or perforation: either percutaneous drainage via
cholecystostomy or cholecystectomy.

Prophylaxis for cholecystectomy

See surgical prophylaxis module for details.
Acute cholecystitis: indicated for all cholecystectomy operations in patients
with acute cholecystitis.
Cefazolin 2g IV within 60 minutes prior to surgical incision.
Routine cholecystectomy: none
Higher risk patients (age > 70, nonfunctioning gallbladder, obstructive
jaundice, or common duct stones).
Also advocated by many clinicians for endoscopic retrograde
cholangiopancreatography.
Antibiotics not needed beyond the operating room time unless suspicion of
infection (implies treatment and not prophylaxis).

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Selected Drug Comments
Drug Recommendation
Ampicillin/sulbactam Good coverage of gram-positive, although in many
communities it now has reduced gram-negative coverage
(e.g., E. coli ~50-60%), due to increasing resistance
making it a poor choice for empiric therapy. It also covers
anaerobic pathogens but lacks Pseudomonas aeruginosa
coverage.
Cefepime Excellent gram-negative coverage and gram-positive
coverage except MRSA and enterococci.
Cefotetan Good single agent coverage of gram-positives, gram-
negatives, and anaerobes, once again available in the U.S.
Imipenem/cilastatin Excellent broad spectrum (gram-positive, gram-negative,
and anaerobe) coverage; would reserve for seriously ill
patients.
Levofloxacin Good gram-positive and gram-negative coverage
Meropenem Excellent broad spectrum (gram-positive, gram-negative,
and anaerobe) coverage; would reserve for seriously ill
patients.

Moxifloxacin Excellent gram-positive, gram-negative, and good

anaerobic coverage.
Piperacillin/tazobactam Improved gram-positive (including Staphylococcus aureus
and coagulase negative staphylococcus species) coverage,
improved gram-negative coverage (B-lactamase producing
pathogens) and improved anaerobic coverage (including
Bacteroides fragilis) compared to piperacillin alone.
Ticarcillin/clavulanic Improved gram-positive (including Staphylococcus aureus
acid and coagulase negative staphylococcus species) coverage,
improved gram-negative coverage (B-lactamase producing
pathogens) and improved anaerobic coverage (including
Bacteroides fragilis) compared to ticarcillin alone.
Ertapenem Gram-positive (except Enterococcus spp.), gram-negative
(except resistant GNR, P. aeruginosa), and anaerobic
coverage - good monotherapy.
Doripenem Newest carbapenem, approved for complicated intra-
abdominal infections in 2007. Gram-positive (except
Enterococcus sp.), gram-negative (including carbapenem
resistant P. aeruginosa), and anaerobic coverage. Would
reserve for seriously ill patients with risk of drug-resistant
pathogens.
Tigecycline Broad spectrum agent with activity against anaerobes,
gram-positive cocci (including resistant pathogens such as
MRSA and VRE), and gram-negative rods (not P. aeruginosa
or Proteus sp.); good choice in patients with high grade
beta-lactam allergies. Pooled analysis of clinical trial data
revealed increased mortality in patients with various
infections when compared with other antibiotics, including
intraabdominal infections.

FOLLOW UP

Early post-operative signs/symptoms often related to inflammation.

Late post-operative signs/symptoms and complications likely infectious.

OTHER INFORMATION

Patients with acute cholecystitis (as opposed to biliary colic) require

hospitalization, and the definitive treatment is cholecystectomy.
Over 90% of patients have calculus cholecystitis. Acalculous cholecystitis has
different epidemiology (less predominant in females and often associated
with other acute events, e.g. trauma).
Chronic cholecystitis is NOT an indication for antibiotic treatment. Should
elective cholecystectomy be performed, preoperative prophylaxis should only
be considered in high risk patients.

Pathogen Specific Therapy expand

Basis for recommendation

1. Solomkin JS et al: Diagnosis and management of complicated intra-abdominal

infection in adults and children: guidelines by the Surgical Infection Society
and the Infectious Diseases Society of America. Clin Infect Dis 50:133, 2010
[PMID:20034345]
Comment: C onsensus recommendations from IDSA, SIS for management of intra-
abdominal infections.

References

1. Sauerland S et al: Laparoscopy for abdominal emergencies: evidence-based

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6/28/2014 Johns Hopkins Guides: Cholecystitis
guidelines of the European Association for Endoscopic Surgery. Surg Endosc
20:14, 2006 [PMID:16247571]
Comment: European guidelines supporting the use of early laparoscopic surgery
for acute cholecystitis.
Rating: Important

2. Strasberg SM: Clinical practice. Acute calculous cholecystitis. N Engl J Med

358:2804, 2008 [PMID:18579815]
Comment: General overview of pathogenesis, microbiology, diagnosis, and
management of cholecystitis.

3. Gurusamy K et al: Meta-analysis of randomized controlled trials on the safety

and effectiveness of early versus delayed laparoscopic cholecystectomy for
acute cholecystitis. Br J Surg 97:141, 2010 [PMID:20035546]
Comment: Meta-analysis demonstrating similar outcomes but shorter length of stay
with early laparoscopic cholecystectomy for acute cholecystitis.

4. Kiewiet JJ et al: A systematic review and meta-analysis of diagnostic

performance of imaging in acute cholecystitis. Radiology 264:708, 2012
[PMID:22798223]
Comment: Outstanding review and meta-analysis of imaging modalities for acute
cholecystitis finding that cholescintigraphy had the highest sensitivity (96%) and
comparable specificity to US and MRI.

5. Pavlidis TE et al: Considerations concerning laparoscopic cholecystectomy in

the extremely elderly. J Laparoendosc Adv Surg Tech A 18:56, 2008
[PMID:18266576]
Comment: Laparoscopic cholecystectomy in the extremely elderly.

6. Elwood DR: Cholecystitis. Surg Clin North Am 88:1241, 2008

[PMID:18992593]
Comment: Overview of cholecystitis, including acalculous cholecystitis.

7. Yokoe M et al: New diagnostic criteria and severity assessment of acute

cholecystitis in revised Tokyo Guidelines. J Hepatobiliary Pancreat Sci
19:578, 2012 [PMID:22872303]
Comment: The 2013 Tokyo Guidelines (TG13) provide an update of the 2007 Tokyo
Guidelines with revised diagnostic criteria that improves specificity without
sacrificing sensitivity; the severity assessment criteria were not changed
significantly from TG07.

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Cholecystitis
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