# Acute Cholecystitis

Acute RUQ Abdominal Pain
Concern for

  • Acute calculous cholecystitis

  • Acute acalculous cholecystitis

  • [Age]-yo [M/F] with PMH of ***, presenting with:

    • *** day constant/intermittent, progressively worsening/improving

    • CC: RUQ abdominal pain

    • gradual/acute onset

    • PP: pain worse with eating, +fever, +N/V

    • PN: denies jaundice, hematemesis, melena, hematochezia, chest pain, SOB

    • pertinent SHx: tobacco, EtOH, drug use

    • Etiology:

      • Calculous: cystic duct obstruction from cholelithiasis (gallstones in gallbladder)

      • Acalculous: gallbladder inflammation without stones, usually in critically ill patients

      • Choledocholithiasis = stones in CBD, may coexist and increase concern for obstruction/cholangitis

    • initial DATA:

      • CBC (WBC)

      • CMP (mild ↑AST/ALT, usually normal bilirubin unless obstruction)

      • mildly ↑ Alk Phos/CRP

      • lipase normal

      • positive Murphy sign

    • pending DATA:

      • RUQ ultrasound:

        • gallbladder wall thickening

        • distention >4 cm

        • pericholecystic fluid

        • gallstones/sludge

        • evaluate for CBD dilation/choledocholithiasis

      • Blood cultures if febrile

      • HIDA if ultrasound nondiagnostic but suspicion remains high

    • MEDS:

      • Pertinent home meds

      • anticoagulation

      • recent antibiotics/immunosuppression

    • COURSE:

      • Monitor for sepsis, perforation, gangrene, emphysematous cholecystitis, CBD obstruction

Plan

  • Consult surgery for early cholecystectomy if stable (within 24–72 hr)

  • If critically ill/high surgical risk:

    • septic shock/hemodynamic instability

    • severe respiratory failure

    • decompensated CHF

    • active MI/severe arrhythmia

    • unreversed anticoagulation

    • severe cirrhosis/frailty

    • extensive local inflammation

    • → stabilize first and consult surgery for percutaneous cholecystostomy

  • IV antibiotics:

    • Ceftriaxone 2 g IV daily + Metronidazole 500 mg IV/PO q8h

    • Severe/septic:

      • Piperacillin-tazobactam 4.5 g IV q6h

      • OR Cefepime + Metronidazole

  • IVF and replete electrolytes PRN

  • NPO for now

  • Pain control:

    • APAP

    • → Ketorolac 15–30 mg q6h PRN if renal function acceptable

    • Avoid NSAIDs in AKI/CKD/GIB

    • If NSAID contraindication/severe pain → Dilaudid PRN

    • Limit opioids when possible (can increase sphincter of Oddi spasm)

  • Blood cultures/lactate if febrile or hemodynamically unstable

  • Trend CBC/CMP/LFTs/bilirubin

  • Evaluate for choledocholithiasis/cholangitis if:

    • jaundice

    • bilirubin elevation

    • CBD dilation

    • cholestatic LFT pattern

    • consider MRCP/ERCP

  • Escalate ICU care if septic shock

Notes

Key Quick Pearls

  • Fever + RUQ pain + Murphy sign → think acute cholecystitis

  • Fever + RUQ pain + jaundice → think acute cholangitis

  • High bilirubin + cholestatic LFTs (↑ Alk Phos/GGT) + CBD dilation → worry about choledocholithiasis/cholangitis

  • Normal bilirubin with RUQ pain/Murphy sign favors cholecystitis

  • AMS + hypotension + jaundice = severe cholangitis/Reynolds pentad

  • Cholangitis is generally the more emergent/septic condition requiring urgent ERCP.

  • Diagnosis:

    • RUQ ultrasound in patient with RUQ pain + fever + Murphy sign

  • Antibiotics can usually stop within 24 hr after uncomplicated cholecystectomy

  • If unable to undergo surgery initially:

    • typically 4–7 days antibiotics

    • interval cholecystectomy in ~6–8 weeks after stabilization

  • Emergent surgery/source control if:

    • emphysematous cholecystitis

    • necrosis/gangrene

    • perforation

    • diffuse peritonitis

ANTIBIOTICS

  • Sepsis (broad)-> (Vanc + Cefepime) , Abdominal concern (+ Flagyl), ESBL risk: (Meropenem + Vanc)

  • Nec Fasc -> Vancomycin + Meropenem + Clindamycin (Meropenem = Cefepime + Metronidazole)

  • CAP-> Ceftriaxone + Azithro (5) ((MRSA/Pseudomonas risk: Cefepime + Vanc ± Azithro (7)))

    • PO: Augmentin + Doxy/Azithro OR Levo, (MRSA: Linezolid)

  • HAP -> Cefepime + Vanc ((septic: Meropenem + Vanc)) (7)

    • PO: Levo/Cipro (psedo) if susceptible + MRSA PO: Linezolid

  • Aspiration Pneumonia- > Ceftriaxone ± Flagyl (7)((Severe: Cefepime + Flagyl)), Abscess/necrosis: 2–6 weeks

    • PO: Augmentin ((Severe Levo + Flagyl))

  • UTI / Pyelonephritis -> Ceftriaxone ((septic: Cefepime)), ESBL: Meropenem , Pyelo: 7–10 days, Complicated/septic: 10–14 days

    • PO -> - TMP-SMX or Levo or Cipro

  • Urosepsis -> Cefepime +VANC ((Shock/ESBL risk: Meropenem)) 7–14 days

    • PO -> - TMP-SMX or Levo or Cipro and (MRSA: Linezolid)

  • Cholangitis / Cholecystitis -> Stable: Ceftriaxone + Flagyl ((Sicker/pseudomonas risk: Cefepime + Flagyl)), Septic shock/ESBL: Meropenem 4–7 days

    • PO-> Augmentin ((Severe Levo + Flagyl))

  • Diverticulitis / Intraabdominal Infection-> Stable: Ceftriaxone + Flagyl 4–7 days((Severe: Cefepime + Flagyl)), ESBL/shock: Meropenem complicated 7–14 days

    • PO-> PO-> Augmentin ((Severe Levo + Flagyl))

  • SBP (Spontaneous Bacterial Peritonitis) -> Ceftriaxone ((septic Cefepime)), ESBL risk: Meropenem (5 day)

    • PO-> TMP-SMX ((Severe Cipro))

  • Cellulitis -> IV: Ceftriaxone

    • PO-> Cephalexin (Penicillin allergy: Clinda) 5–7 days

  • Purulent / Abscess -> Vanc

    • PO Step-down TMP-SMX , or doxy or Linezolid 5–10 days

  • Diabetic Foot Infection -> Mild PO: Cephalexin ± Doxy, sever-> IV: Vanc + Cefepime + Flagyl ((ESBL risk: Meropenem + Vanc)),

    • PO-> Augmentin or Levo + Flagyl

  • Osteomyelitis -> CTX + Vanc ((Polymicrobial: Vanc + Cefepime + Flagyl))

    • PO Linezolid or TMP-SMX or levo or clinda 4–6 weeks

  • Septic Arthritis -> Vanc + Ceftriaxone ((IVDU/pseudomonas risk: Vanc + Cefepime))

    • PO-. TMP-SMX 2–4 weeks

  • Meningitis -> Vanc + Ceftriaxone ((Age >50/immunocompromised: add Ampicillin)) , Healthcare-associated: Vanc + Cefepime

    • Typically prolonged IV therapy (ID consult) - Pneumococcal: 10–14 days Meningococcal: ~7 days

  • Bacteremia / Sepsis Unknown Source-> Vanc + Cefepime ((Abdominal concern: add Flagyl)), ESBL risk: Meropenem + Vanc

    • PO MRSA bacteremia: -> prolonged IV , Sometimes Linezolid

    • Gram-negative bacteremia:- > Levo or Cioro, or tmp-smx 7–14 days

  • Infective Endocarditis -> Vanc + Ceftriaxone ((Prosthetic valve: Vanc + Cefepime))

    • Mostly prolonged IV therapy Usually 4–6 weeks IV

  • Necrotizing Fasciitis / Fournier Gangrene -> Vanc + Meropenem + Clinda OR Vanc + Cefepime + Flagyl + Clinda

    • PO Rare early PO , later Augmentin or TMP-SMX or Linezolid (ID) 2–3+ weeks

  • C. diff Colitis -> PO vanc or Fidaxomicin ((Fulminant :PO Vanc + IV Flagyl))

    • Usually 10 days

  • Neutropenic Fever - > Cefepime+ vanc (ESBL/shock: Meropenem)

    • PO-> Depends ANC recovery/cultures , Levo

  • PID (Pelvic Inflammatory Disease) -> Ceftriaxone + Doxy + Flagyl

    • PO -> Doxy + Flagyl 14 days total

  • Bite Wounds (Human/Animal) -> IV severe: Unasyn

    • Po-> Augmentin or Clinda 5–7 days

  • Dental / Odontogenic Infection -> - Unasyn OR Ceftriaxone + Flagyl

    • Po-> Augmentin or Clinda 5–7 days

  • ESBL risk → prior ESBL, heavy FQ exposure, LTCF/recurrent hospitalization → use Meropenem

  • MRSA risk → prior MRSA, HD, IVDU, purulence, healthcare exposure, severe sepsis → add Vancomycin (or Linezolid/Daptomycin)

  • Pseudomonas risk → structural lung disease, prior Pseudomonas, prolonged/recent antibiotics, ICU/healthcare exposure → use Cefepime, Zosyn, or Meropenem ± double coverage if critically ill