Cholecystitis

Criteria	Findings
Clinical Criteria
Local signs of inflammation	- Murphy's sign
	- Right upper quadrant mass, pain, or tenderness
Systemic signs of inflammation	- Fever
	- Elevated C-reactive protein (CRP)
	- Elevated white blood cell count (WBC)
Imaging Findings
	- Gallbladder wall thickening (>4 mm)
	- Pericholecystic fluid
	- Gallbladder distention
	- Gallstones or sludge
	- Positive sonographic Murphy's sign

Severity Grade	Criteria	Management
Grade I (Mild)	- Does not meet criteria for Grade II or III - No organ dysfunction	- Conservative Treatment: - NPO (Nothing by mouth) - IV Fluids to maintain hydration and electrolyte balance - Analgesia: NSAIDs (e.g., ibuprofen 400-800 mg every 6-8 hours) or opioids (e.g., morphine 2-4 mg IV every 4-6 hours) - Antibiotics targeting common biliary pathogens (e.g., Ceftriaxone 1-2 g IV every 24 hours + Metronidazole 500 mg IV every 8 hours) - Elective Laparoscopic Cholecystectomy after inflammation subsides
Grade II (Moderate)	- Elevated WBC count (>18,000/mm³) - Palpable tender mass in RUQ - Duration of symptoms >72 hours - Marked local inflammation (e.g., gangrenous cholecystitis, pericholecystic abscess)	- Conservative Treatment: - Similar to Grade I but with closer monitoring - Early Laparoscopic Cholecystectomy: - Ideally within 72 hours of presentation, especially for cases with gangrenous or complicated cholecystitis
Grade III (Severe)	- Cardiovascular dysfunction (hypotension requiring treatment) - Neurological dysfunction (altered mental status) - Respiratory dysfunction (PaO2/FiO2 ratio <300) - Renal dysfunction (oliguria, creatinine >2.0 mg/dL) - Hepatic dysfunction (INR >1.5) - Hematological dysfunction (platelet count <100,000/mm³)	- ICU Admission: - Essential for organ support and close monitoring - Aggressive Conservative Treatment: - NPO, IV Fluids, Analgesia, Antibiotics (e.g., Piperacillin/Tazobactam 4.5 g IV every 8 hours or Carbapenem based on institutional protocols) - Organ support tailored to specific dysfunction (e.g., vasopressors for hypotension, mechanical ventilation for respiratory failure) - Percutaneous Cholecystostomy: - Consider for critically ill patients who cannot tolerate surgery - Delayed/Interval Laparoscopic Cholecystectomy: - Performed after stabilization of organ dysfunction and improvement of the inflammatory process

Order Antibiotics Form

Medication	Dose	Route	Frequency	Duration
Ceftriaxone	2 grams	IV	Once daily	Until further notice or 7 days
Metronidazole	500 mg	IV	Every 8 hours	Until further notice or 7 days

General Notes

Figure 1: Grade I (Mild) Acute Cholecystitis

Figure 2: Grade II (Moderate) Acute Cholecystitis

Figure 3: Grade III (Severe) Acute Cholecystitis

Important Reminders

Adapted from 'Tokyo Guidelines 2018: Diagnostic criteria and severity grading of acute cholecystitis,' Journal of Hepato-Biliary-Pancreatic Sciences, 2018. © The Authors. Published by Wiley Periodicals, Inc. on behalf of Japanese Society of Hepato-Biliary-Pancreatic Surgery. Available at: https://onlinelibrary.wiley.com/doi/full/10.1002/jhbp.516.

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Introduction

Cholecystitis, the inflammation of the gallbladder, is a frequent encounter for surgical residents. This article provides a comprehensive review encompassing the pathophysiology, diagnosis, and management of cholecystitis, with a focus on practical aspects relevant to surgical residents.

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I. Pathophysiology & Etiology: Back to the Basics

1. What happens in cholecystitis?

• Obstruction: Cholecystitis typically starts with an obstruction of the cystic duct, most commonly due to gallstones. This obstruction leads to bile stasis and increased pressure within the gallbladder.

• Inflammation: The trapped bile irritates the gallbladder wall, triggering an inflammatory response. This initially causes edema and wall thickening, which can progress to ischemia, necrosis, and eventually perforation.

• Bacterial Infection: In many cases, bacteria from the gut (such as E. coli, Klebsiella, and Enterococcus) can enter the stagnant bile, causing a secondary bacterial infection that worsens the inflammation.
  

2. What causes cholecystitis?

• Gallstones (Calculous Cholecystitis): The most common cause, accounting for 90-95% of cases. These stones, made of cholesterol or bile pigments, can obstruct the cystic duct.

• Acalculous Cholecystitis: Occurs without gallstones, often in critically ill patients, those with significant trauma, or following major surgery. It is thought to be caused by decreased gallbladder motility, bile stasis, and ischemia.
  

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II. Diagnosis: Connecting the Dots

A. Clinical Presentation:

• History:

  • RUQ pain: Typically colicky, severe, and may radiate to the right shoulder or back. Worsens after fatty meals.

  • Nausea & Vomiting: Commonly associated symptoms.

  • Fever: Indicates systemic inflammation and possible infection.

• Physical Examination:

  • RUQ Tenderness: Hallmark sign, localized to the gallbladder area.

  • Murphy's Sign: Sharp pain and inspiratory arrest upon deep palpation of the RUQ during inspiration.

  • RUQ Mass: May be palpable in cases of severe inflammation or empyema.
    

B. Laboratory Findings:

• Elevated WBC count: Typically above 10,000/mm³, with a left shift (increased neutrophils) suggesting bacterial infection.

• Elevated CRP: A non-specific marker of inflammation, often significantly elevated in cholecystitis.

• Elevated Liver Enzymes (AST, ALT): Mild elevations may be seen due to inflammation near the liver.

• Elevated Bilirubin: May indicate common bile duct obstruction (choledocholithiasis).
  

C. Imaging Studies:

• 1. Ultrasonography (US):

  • First-line Imaging: Non-invasive, widely available, and highly accurate for diagnosing cholecystitis.

  • Key Findings:

    • Gallstones: Echogenic structures with posterior acoustic shadowing.

    • Gallbladder Wall Thickening: > 4 mm (normal is < 3 mm).

    • Pericholecystic Fluid: Anechoic fluid collection surrounding the gallbladder.

    • Sonographic Murphy's Sign: Pain elicited by the transducer pressure over the gallbladder.

• 2. Computed Tomography (CT):

  • Useful when US is inconclusive: Can better define complications like perforation, abscess, and pancreatitis.

  • Key Findings:

    • Wall thickening and pericholecystic fluid: Similar to US.

    • Gallbladder distention: Enlarged gallbladder with air-fluid levels in emphysematous cholecystitis.

    • Pericholecystic inflammation: Fat stranding and fluid around the gallbladder.

• 3. Magnetic Resonance Imaging (MRI/MRCP):

  • Provides excellent anatomical detail: Useful for evaluating bile duct anatomy, especially for suspected choledocholithiasis.

  • Key Findings:

    • High signal intensity of gallbladder wall: On T2-weighted images, indicating edema and inflammation.

    • Biliary obstruction: Dilated bile ducts proximal to the obstruction.
      

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III. Severity Grading: Guiding Treatment Decisions

The TG18 classifies cholecystitis into three grades to help tailor management strategies:

Grade I (Mild):

• Criteria:

  • No organ dysfunction.

  • Mild local inflammation (e.g., tenderness, wall thickening on US).

• Management:

  • Conservative Treatment:

    • NPO: Rest the gallbladder by avoiding oral intake.

    • IV Fluids: Maintain hydration and electrolyte balance.

    • Analgesia: NSAIDs (e.g., ibuprofen 400-800mg every 6-8 hours, ketorolac 15-30mg IV every 6 hours) for mild to moderate pain; opioids (e.g., morphine 2-4mg IV every 4-6 hours, hydromorphone 0.2-0.4mg IV every 2-4 hours) for severe pain.

    • Antibiotics: Target common biliary pathogens (see section IV for details).

  • Elective Laparoscopic Cholecystectomy: Ideally performed after the acute inflammation subsides.

Grade II (Moderate):

• Criteria:

  • One or more of the following:

  • Elevated WBC count (> 18,000/mm³)

  • Palpable tender mass in RUQ

  • Symptoms for > 72 hours

  • Marked local inflammation (e.g., gangrenous cholecystitis, pericholecystic abscess)

• Management:

  • Conservative Treatment: Similar to Grade I, but may require closer monitoring.

  • Early Laparoscopic Cholecystectomy: Ideally within 72 hours of presentation, especially for cases with gangrenous or complicated cholecystitis.

Grade III (Severe):

• Criteria: Organ dysfunction in any system (cardiovascular, neurological, respiratory, renal, hepatic, hematological).

• Management:

  • ICU Admission: Essential for organ support and close monitoring.

  • Aggressive Conservative Treatment:

    • NPO, IV Fluids, Analgesia, Antibiotics: As described above.

    • Organ Support: Tailored to the specific organ dysfunction (e.g., vasopressors for hypotension, mechanical ventilation for respiratory failure).

  • Percutaneous Cholecystostomy: Consider for critically ill patients who cannot tolerate surgery.

  • Delayed/Interval Laparoscopic Cholecystectomy: Performed after stabilization of organ dysfunction and improvement of the inflammatory process.
    

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IV. Management: A Resident's Approach

• 1. Antimicrobial Therapy:

  • Empirical Therapy: Start broad-spectrum antibiotics that cover common biliary pathogens, considering local antibiograms and severity.

    • Mild/Moderate: Ceftriaxone 1-2g IV every 24 hours + Metronidazole 500mg IV every 8 hours. Alternatives: Piperacillin/Tazobactam 3.375g IV every 6 hours, Ampicillin/Sulbactam 3g IV every 6 hours.

    • Severe: Broader coverage with Piperacillin/Tazobactam 4.5g IV every 8 hours or Carbapenem (e.g., Imipenem/Cilastatin, Meropenem, Doripenem, Ertapenem) based on institutional protocols.

  • Targeted Therapy: Adjust antibiotics based on culture results once available. De-escalation to narrower-spectrum antibiotics is encouraged.

Severity	Empirical Therapy	Alternatives
Mild/Moderate	- Ceftriaxone: 1-2 g IV every 24 hours + Metronidazole: 500 mg IV every 8 hours	- Piperacillin/Tazobactam: 3.375 g IV every 6 hours or - Ampicillin/Sulbactam: 3 g IV every 6 hours
Severe	- Piperacillin/Tazobactam: 4.5 g IV every 8 hours or - Carbapenem (e.g., Imipenem/Cilastatin, Meropenem, Doripenem, Ertapenem) based on institutional protocols

Targeted Therapy

• Adjust antibiotics based on culture results once available.

• De-escalation to narrower-spectrum antibiotics is encouraged.

• 2. Supportive Care:

  • NPO & IV Fluids: Maintain adequate hydration and electrolyte balance.

  • Pain Management: Aggressive pain control with NSAIDs or opioids as needed.

  • Nausea & Vomiting Management: Antiemetics (e.g., ondansetron, promethazine) may be necessary.
    

• 3. Definitive Treatment: Cholecystectomy

  • A. Laparoscopic Cholecystectomy (LC):

    • Gold Standard: Minimally invasive, offering faster recovery, less pain, and shorter hospital stays compared to open surgery.

    • Technique:

      • Pneumoperitoneum: Created using CO2 insufflation.

      • Trocar Placement: Typically four trocars are used for access and instrument manipulation.

      • Dissection: The gallbladder is carefully dissected from the liver bed, identifying and isolating the cystic duct and artery.

      • Critical View of Safety (CVS): Crucial step to avoid bile duct injury. Ensure you can clearly visualize:

      • The cystic plate (inferior wall of the liver bed).

      • Two structures entering the gallbladder (cystic duct and artery).

      • No other structures nearby (common bile duct, hepatic artery).

      • Clipping & Division: The cystic duct and artery are clipped and divided.

      • Gallbladder Removal: The gallbladder is extracted through one of the trocar sites.

    • Challenges in Acute Cholecystitis:

      • Inflammation & Fibrosis: Can obscure anatomical landmarks, making dissection challenging.

      • Increased Risk of Bile Duct Injury: Due to distorted anatomy and adhesions.

      • Difficult Dissection: May require advanced laparoscopic skills and meticulous technique.

• B. Open Cholecystectomy:

  • Reserved for Complicated Cases: When LC is not feasible or too risky due to:

    • Severe inflammation and adhesions.

    • Gallbladder perforation.

    • Bleeding complications.

    • Suspected malignancy.

  • Technique: Involves a larger incision (typically right subcostal or midline) for direct visualization and dissection of the gallbladder.

• C. Percutaneous Cholecystostomy (PC):

  • Temporary Drainage Procedure: Performed under imaging guidance (US or fluoroscopy) to drain the gallbladder and relieve symptoms in critically ill patients.

  • Technique:

    • Gallbladder Puncture: A needle is inserted into the gallbladder through the abdominal wall.

    • Catheter Placement: A drainage catheter is placed into the gallbladder and secured to the skin.

  • Advantages: Minimally invasive and can be performed in patients who are not surgical candidates.

  • Limitations: Temporary solution, does not address the underlying cause (gallstones), and carries a risk of bile leak or catheter dislodgment.
    

• 4. Postoperative Care:

  • Pain Management: Continue pain control with oral or IV analgesics.

  • Diet: Gradual reintroduction of a regular diet as tolerated.

  • Ambulation: Encourage early ambulation to prevent complications like atelectasis and DVT.

  • Wound Care: Monitor for signs of infection or bile leak.

  • Follow-up: Ensure adequate follow-up to address any residual symptoms or complications.
    

Conclusion

Cholecystitis, the inflammation of the gallbladder, is a common condition encountered by surgical residents. Understanding its pathophysiology, diagnosis, and management is crucial for providing effective patient care. This article has provided a comprehensive review, emphasizing practical aspects relevant to surgical residents.

Key Points Recap:

• Pathophysiology & Etiology:

  • Obstruction: Usually caused by gallstones, leading to bile stasis and increased pressure within the gallbladder.

  • Inflammation: Triggered by trapped bile, which can progress to ischemia, necrosis, and perforation.

  • Bacterial Infection: Often secondary to the obstruction, commonly involving gut bacteria such as E. coli and Klebsiella.

• Diagnosis:

  • Clinical Presentation: RUQ pain, nausea, vomiting, and fever are key symptoms. Physical examination findings include RUQ tenderness, Murphy's sign, and sometimes a palpable mass.

  • Laboratory Findings: Elevated WBC count, CRP, liver enzymes, and bilirubin.

  • Imaging Studies: Ultrasound is the first-line imaging modality, with CT and MRI/MRCP as additional tools for more detailed assessment.

• Severity Grading:

  • Grade I (Mild): No organ dysfunction, mild local inflammation. Managed conservatively with NPO, IV fluids, analgesia, antibiotics, and elective laparoscopic cholecystectomy.

  • Grade II (Moderate): Features more severe local inflammation. Managed with early laparoscopic cholecystectomy.

  • Grade III (Severe): Associated with organ dysfunction. Requires ICU admission, aggressive conservative treatment, and percutaneous cholecystostomy for critically ill patients.

• Management:

  • Antimicrobial Therapy: Empirical broad-spectrum antibiotics, with adjustments based on culture results and de-escalation to narrower-spectrum antibiotics.

  • Supportive Care: NPO, IV fluids, pain management, and antiemetics.

  • Definitive Treatment:

    • Laparoscopic Cholecystectomy: The gold standard for most patients.

    • Open Cholecystectomy: Reserved for complicated cases.

    • Percutaneous Cholecystostomy: Temporary drainage for critically ill patients.

• Postoperative Care:

  • Pain management, gradual reintroduction of diet, early ambulation, wound care, and follow-up.