UPDATE ON

MANAGEMENT OF
ACUTE
CHOLECYSTITIS
I KETUT SUDARTANA, MD., PHD.
INTRODUCTION
 80% of gallstones remain asymptomatic, but they can obstruct the cystic duct.
 Prolonged obstruction can lead to inflammation of the duct, leading to inflammation
of the gallbladder known as acute cholecystitis (AC).
 In people below 50 years of age, women are three times more likely than men to
develop AC.
 Repeated acute cholecystitis episodes can cause chronic cholecystitis, characterized
by thickened gallbladder (GB) wall, GB mucosal atrophy, and scarring.
DIAGNOSIS
The diagnostic criteria according to Tokyo Guideline 2018 (TG18):
A. Local sign of inflammation (for example: Murphy’s sign)
B. Systemic sign of inflammation (for example: fever, elevated CRP, elevated WBC
count)
C. Imaging findings.
Presence of criteria A and B = Suspected diagnosis.
Presence of criteria A, B, and C = Definitive diagnosis.
SEVERITY GRADING
Tokyo Guideline 2018 (TG18):
Grade 1 : AC in healthy patient with mild inflammation, but without organ
dysfunction.
Grade 2 : AC with WBC count over 18.000 cells/mm3, palpable tender mass at Right
Upper Quadrant (RUQ), symptoms lasting >72 hours, or evidence of marked local
inflammation.
Grade 3 : AC with associated organ dysfunction.
INITIAL THERAPY
 Initial treatment includes bowel rest, IV hydration, electrolyte correction, analgesia, and
IV antibiotic.
 For mild cases, single broad spectrum antibiotic is adequate.

Antibiotic recommendations:
 Piperacillin/tazobactam (3.375 g IV q6h or 4.5 g IV q8h),
 Ampicillin/sulbactam (3 g IV q6h)
 Meropenem (1 g IV q8h).

In severe life-threatening cases = imipenem/cilastatin (500 mg IV q6h).

NON-SURGERY TREATMENT
 Cholecystitis is best treated with surgery, but it can be treated conservatively if
necessary.
 Gall bladder drainage can be performed as an alternative if the patient is acutely ill
and is a poor surgical candidate. Percutaneous and endoscopic drainage are available.
 Dietary adjustments of low-fat and low-spice diets may also be useful, results will
vary.
 Treatment of gallstones with Ursodiol has reports of occasional success.
SURGICAL INTERVENTION
 Early Laparoscopic Cholecystectomy (LC) has become the standard, replacing
Open Cholecystectomy (OC).
 LC has a significantly shorter postoperative recovery time, and there are no
significant differences with OC in procedure duration, morbidity, or mortality.
 LC should be performed within 72 hours of AC symptom presentation, if possible. If
the onset is delayed beyond 72 hours, recent studies suggest that early LC is still
preferable to delayed LC (further investigation is needed).
DIFFICULT CHOLECYSTECTOMY

Risk factors that predict a technically difficult cholecystectomy:

 Symptom onset > 72 hours.
 WBC count > 18.000/mm3
 Palpable GB, or
 Gangrenous GB.

Technically difficult cholecystectomy has higher chance of biliary duct injury (BDI).
DIFFICULT CHOLECYSTECTOMY
The Society of American Gastrointestinal and Endoscopic Surgeons’ (SAGES) six-step Safe
Cholecystectomy Program (SCP):
 Achieving critical view of safety (CVS).
 Recognizing aberrant anatomy.
 Performing an intra-operative time out before clipping or cutting ductal structures.
 Liberal use of intraoperative cholangiogram.
 Devising bail-out options.
 Asking for help in difficult cases.
DIFFICULT CHOLECYSTECTOMY

Achievement of CVS is defined by the following criteria:

 The hepatocystic triangle is cleared of fat and fibrous tissue.
 The lower one‐third of the GB is separated from the liver to expose the cystic plate,
and
 No more than two structures should be seen entering the GB.
DIFFICULT CHOLECYSTECTOMY

 If sufficient anatomy guidance cannot be achieved even with the use of additional
techniques, conversion to an open procedure is likely indicated.
 If CVS cannot be achieved, executing bail out options may be necessary.
PERCUTANEOUS CHOLECYSTOSTOMY

 Percutaneous Cholecystostomy (PC) is the preferred alternative to LC in patients

with high risk of postoperative mortality such as the elderly or critically ill.
 However, PC can be a technically difficult procedure with potentially high conversion
rate.
 Compared to open and laparoscopic cholecystectomy, PC is associated with
significantly longer duration of intensive care unit stays, more complications, and
higher readmission rates.
PERCUTANEOUS CHOLECYSTOSTOMY

 Precise indications for PC has not yet been found, but there is consensus that PC
should be done early (<24 hours post-symptom onset).
 Optimal timing to remove the GB after PC is still controversial.
COMPLICATIONS

 Empyema of the gallbladder.

 Gallstone ileus.
 Sepsis.
 Pancreatitis.
 THANK YOU
FOR YOUR
ATTENTION

Mou D, Tesfasilassie T, Hirji S, Ashley SW. Advances in the management of acute cholecystitis. Ann Gastroenterol Surg. 2019;3(3):247–253. Published 2019 Feb 19.
doi:10.1002/ags3.12240

Jones MW, Genova R, O'Rourke MC. Acute Cholecystitis. [Updated 2019 Oct 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK459171/

https://emedicine.medscape.com/article/171886-overview