← Diagnosis and Management Guides
Acute Cholecystitis
Key considerations: Ascending cholangitis, Gallstone pancreatitis, Cholecystoenteric fistula
Cannot miss
- Ascending cholangitis
- Gallstone pancreatitis
- Cholecystoenteric fistula
- Emphysematous cholecystitis
Likely diagnoses
- Acute calculous cholecystitis
- Biliary colic
- Peptic ulcer disease
- Hepatitis
Red flags
- Fever with jaundice and RUQ pain (Charcot triad = cholangitis)
- Peritoneal signs
- Altered mental status + hypotension (Reynolds pentad)
Workup
- history: RUQ pain, postprandial, nausea/vomiting, fever, prior episodes, food triggers; exam: RUQ tenderness, Murphy sign, jaundice; labs: CBC, CMP (LFTs, bilirubin), lipase, blood cultures if febrile; imaging: RUQ ultrasound: gallstones, GB wall thickening >3mm, pericholecystic fluid, sonographic Murphy sign; HIDA scan if US equivocal; bedside: Point-of-care ultrasound for gallstones and Murphy sign
Management
- immediate: NPO, IV fluids, IV antibiotics (cefoxitin or pip-tazo); Pain management (ketorolac, opioids); general: Cholecystectomy within 72 hours (early preferred over delayed); If poor surgical candidate: percutaneous cholecystostomy; Cholangitis: ERCP for biliary decompression
Disposition
- admit: All acute cholecystitis for surgery; discharge: Only biliary colic without cholecystitis — surgical referral for elective cholecystectomy; consults: Surgery, GI if ERCP needed for choledocholithiasis/cholangitis
Clinical pearls
- Murphy sign is the most useful bedside finding — sensitivity ~65%, specificity ~87%
- Early cholecystectomy (<72hr) has lower complication rates than delayed surgery
- Acalculous cholecystitis occurs in critically ill patients — think GB ischemia
Source and review
- Tokyo Guidelines 2018. Last reviewed: 2024-11-01