Acute Cholecystitis

Key considerations: Gallbladder perforation, Cholangitis (Charcot triad/Reynolds pentad), Emphysematous cholecystitis

Cannot miss

history: RUQ pain >6 hours (biliary colic is typically <6h); Prior biliary colic episodes; Fever, nausea, vomiting; Fatty food intolerance; exam: Murphy sign (inspiratory arrest during RUQ palpation); RUQ tenderness; Jaundice (suggests CBD stone or cholangitis); Fever; labs: CBC (leukocytosis); LFTs (AST, ALT, AlkPhos, bilirubin); Lipase (rule out gallstone pancreatitis); Blood cultures if febrile; imaging: RUQ ultrasound: gallstones, GB wall thickening (>3mm), pericholecystic fluid, sonographic Murphy; HIDA scan if US equivocal (non-filling = cystic duct obstruction); CT if concerned for complications; bedside: POCUS for gallstones, wall thickening, pericholecystic fluid, CBD dilation

immediate: NPO; IV fluids; IV antibiotics (cefoxitin, or ceftriaxone + metronidazole); Pain management (ketorolac, opioids); general: Surgical consult for cholecystectomy; Early cholecystectomy (within 72h) preferred over delayed; specific: diagnosis: Uncomplicated; steps: Laparoscopic cholecystectomy within 24-72 hours; IOC if concern for CBD stones; diagnosis: Cholangitis; steps: Urgent ERCP for CBD decompression; Broad-spectrum antibiotics (pip-tazo); Cholecystectomy after cholangitis resolves; diagnosis: High Surgical Risk; steps: Percutaneous cholecystostomy tube; Antibiotics; Interval cholecystectomy when stable

admit: All acute cholecystitis; Cholangitis (ICU if septic); discharge: Resolved biliary colic with surgical follow-up for elective cholecystectomy; consults: General surgery; GI/ERCP if CBD stone or cholangitis

Biliary colic (<6h) vs cholecystitis (>6h of unrelenting pain with fever) — duration differentiates
Acalculous cholecystitis: think ICU patients, diabetics, HIV — high mortality (30-50%)
Tokyo Guidelines 2018: Grade I (mild), II (moderate — WBC >18k, mass, symptoms >72h), III (severe — organ dysfunction)