What are the guideline sources, guidelines and references for Acute cholecystitis ?
Guideline sources The following summarized guidelines for the evaluation and management of acute cholecystitis are prepared by our editorial team based on guidelines from the Danish Surgical Society (DSS 2022), the World Society of Emergency Surgery (WSES 2020), the World Society of Emergency Surgery (WSES/SICG 2019), the Tokyo Guidelines (TG 2018), the European Association for the Study of the Liver (EASL 2016), and the American Society for Gastrointestinal Endoscopy (ASGE 2015). 1 2 3 4 5 6 7 8 9 10 11 11 12 Definition Acute cholecystitis is an inflammation of the gallbladder and is usually caused by obstruction of the cystic duct. 10 Epidemiology Acute cholecystitis is mostly caused by gall stones or by impacted biliary sludge with or without secondary bacterial infection (E. coli, Klebsiella, and Streptococcus faecalis). 11 Disease course https://web.pathway.md/diseases/recSrhoDrXV1gdurf 1/9 6/23/23, 1:43 AM Acute cholecystitis Pathway The inflammatory process due to obstruction of cystic duct results in acute cholecystitis, which causes clinical manifestations of persistent pain and tenderness in the RUQ, and mild jaundice. Disease progression may lead to gangrenous cholecystitis, gallbladder perforation, cholecystoenteric fistulas, gallstone ileus, and acalculous cholecystitis. 11 Prognosis and risk of recurrence In the US, the overall mortality associated with untreated complications of acute cholecystitis is approximately 20%. 12 Guidelines 1. Screening and diagnosis Clinical presentation: As per TG 2018 guidelines, recognize that severe (grade III) acute cholecystitis causes systemic symptoms because of organ damage and affects survival prognosis. B As per EASL 2016 guidelines, suspect acute cholecystitis in patients with fever, severe pain located in the right upper abdominal quadrant lasting for several hours, and right upper abdominal tenderness on palpation. B Diagnostic criteria: use the TG18/TG13 criteria for the diagnosis of acute cholecystitis. B 2. Classification and risk stratification Severity grading and prognosis: As per WSES 2020 guidelines, insufficient evidence to suggest the use of any prognostic model in patients with acute calculous cholecystitis. I As per TG 2018 guidelines, use the TG18/TG13 severity grading for the assessment of severity of acute cholecystitis and for predicting prognosis: Situation Guidance No organ dysfunction and mild inflammatory changes in the gallbladder Grade I Leukocytosis > 18, 000/mm Grade II RUQ palpable tender mass Duration of complaints > 72 hours Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis) https://web.pathway.md/diseases/recSrhoDrXV1gdurf 2/9 6/23/23, 1:43 AM Acute cholecystitis Pathway Grade III Cardiovascular dysfunction (hypotension requiring treatment with dopamine 5 g/kg/min, or any dose of norepinephrine) Neurological dysfunction (decreased level of consciousness) Respiratory dysfunction (PaO /FiO ratio < 300) Renal dysfunction (oliguria or creatinine > 2.0 mg/dL) Hepatic dysfunction (INR) > 1.5 Hematological dysfunction (thrombocytopenia < 100, 000/mm ). B Risk stratification of choledocholithiasis: Consider stratifying the risk of choledocholithiasis according to the proposed classification modified from the ASGE and SAGES guidelines. C Use the classification scheme recommended for the general population to assess the risk of choledocholithiasis in elderly patients with acute cholecystitis. B Risk stratification of elderly patients: Evaluate the risk for elderly patients with acute calculous cholecystitis by including: mortality rate for conservative and surgical therapeutic options rate of gallstone-related disease relapse and the time to relapse age-related life expectancy frailty evaluation by the use of frailty scores estimation of specific risks (patient/type of surgery) by the use of surgical clinical scores. B 3. Diagnostic investigations General principles: Consider using a combination of detailed history, complete clinical examination, laboratory tests, and imaging for the diagnosis of acute calculous cholecystitis, although recognize that the best combination is not known. C Do not rely on a single clinical or laboratory finding to confirm or exclude acute cholecystitis. D Abdominal ultrasound: As per WSES 2020 guidelines: Obtain abdominal ultrasound as the initial imaging in patients with suspected acute calculous cholecystitis, due to its cost-effectiveness, wide availability, reduced invasiveness and good accuracy for gallstones disease. A https://web.pathway.md/diseases/recSrhoDrXV1gdurf 3/9 6/23/23, 1:43 AM Acute cholecystitis Pathway Consider visualizing stones in the common bile duct on abdominal ultrasound as a predictor of choledocholithiasis in patients with acute calculous cholecystitis. C As per TG 2018 guidelines: Obtain abdominal ultrasound as the first-choice imaging for the morphological diagnosis of acute cholecystitis, due to its low invasiveness, widespread availability, ease of use, and cost- effectiveness. B Avoid obtaining color or power Doppler ultrasound for the diagnosis of acute cholecystitis. Recognize that the evaluation of blood flow by Doppler ultrasound is strongly affected by factors such as device performance and the patient's body type which makes quantification difficult. D Further imaging, general population: As per WSES 2020 guidelines, consider obtaining further imaging for the diagnosis of acute calculous cholecystitis in selected patients, depending on local expertise and availability, recognizing that: hepatobiliary iminodiacetic acid scan has the highest sensitivity and specificity for the diagnosis of acute calculous cholecystitis diagnostic accuracy of CT is poor MRI has the same accuracy as abdominal ultrasound. B As per TG 2018 guidelines: Consider obtaining the following investigations to reduce the risk of bile duct injury in patients with acute cholecystitis: preoperative MRCP intraoperative fluorescence cholangiography intraoperative ultrasound. C Insufficient evidence to support the use of intraoperative cholangiography to reduce the risk of bile duct injury in patients with acute cholecystitis. I As per TG 2018 guidelines, obtain MRI/MRCP for the diagnosis of acute cholecystitis if abdominal ultrasound does not provide a definitive diagnosis. B Show 2 more As per EASL 2016 guidelines, consider obtaining abdominal CT in patients with a strong clinical suspicion of acute cholecystitis. C Further imaging (elderly patients): Recognize that: evidence on the diagnostic accuracy of CT are scarce and remain elusive diagnostic accuracy of MRI might be comparable to that of abdominal ultrasound in elderly patients, but no sufficient data are provided to support this hypothesis hepatobiliary iminodiacetic acid scan has the highest sensitivity and specificity for acute cholecystitis than other imaging modalities although its scarce availability, long time of execution and exposure to ionizing radiations limit its use. B Laboratory tests: https://web.pathway.md/diseases/recSrhoDrXV1gdurf 4/9 6/23/23, 1:43 AM Acute cholecystitis Pathway Obtain ALT, AST, GGT, bilirubin, and ALP to assess the risk of choledocholithiasis in all patients with acute calculous cholecystitis. B Insufficient evidence to support the use of procalcitonin for the diagnosis or severity grading in patients with acute cholecystitis. I Do not obtain routine blood cultures in patients with mild (grade I) community-acquired acute cholecystitis. D Evaluation for choledocholithiasis: Obtain the following tests to assess the risk of choledocholithiasis in patients with acute calculous cholecystitis: ALT, AST, GGT bilirubin, ALP abdominal ultrasound. B Show 4 more 4. Medical management Indications for non-operative management: Consider offering nonoperative management with antibiotics and observation in patients with acute calculous cholecystitis refusing or not suitable for surgery. C Consider offering alternative treatment options (such as gallstone dissolution or extracorporeal shock wave lithotripsy) in patients with acute calculous cholecystitis who have failed nonoperative management and are still refusing or not suitable for surgery. C Antibiotic therapy, general population: As per WSES 2020 guidelines: Administer antibiotics in patients with complicated acute calculous cholecystitis, based on the presumed pathogens and risk factors for major resistance patterns. A Adapt the targeted antibiotic regimen to the results of microbiological analysis, ensuring adequate antimicrobial coverage in patients at high risk for antimicrobial resistance or with complicated acute calculous cholecystitis. B As per TG 2018 guidelines, administer antimicrobial therapy in patients with mild-to-moderate (grade I-II) acute cholecystitis only before and at the time of surgery. B Show 3 more As per EASL 2016 guidelines, do not administer antibiotics in patients with mild acute cholecystitis without cholangitis, bacteremia/sepsis, abscess or perforation. D Antibiotic therapy (elderly patients): Administer broad-spectrum antibiotics in elderly patients with complicated acute cholecystitis. Guide the empiric antibiotic therapy by most frequently isolated bacteria taking into consideration antibiotic resistance and the clinical condition of the patient. B Consider using the results of microbiological analysis in designing targeted therapeutic strategies for individual patients with healthcare infections to customize antibiotic treatments and https://web.pathway.md/diseases/recSrhoDrXV1gdurf 5/9 6/23/23, 1:43 AM Acute cholecystitis Pathway ensure adequate antimicrobial coverage. B 5. Perioperative care Preoperative antibiotics: avoid administering routine antibiotic prophylaxis before elective laparoscopic cholecystectomy. D Postoperative antibiotics: do not administer routine postoperative antibiotics in patients with uncomplicated acute calculous cholecystitis if the focus of infection is controlled by cholecystectomy. D 6. Surgical interventions Cholecystectomy, indications: As per DSS 2022 guidelines, consider performing acute laparoscopic cholecystectomy in favor of gallbladder drainage in high-risk patients with acute cholecystitis. C As per WSES 2020 guidelines, perform laparoscopic cholecystectomy as first-line treatment in patients with acute calculous cholecystitis. A Show 2 more As per SICG/WSES 2019 guidelines, perform cholecystectomy as the preferred treatment of acute cholecystitis in elderly patients. B Show 3 more Cholecystectomy, timing: As per DSS 2022 guidelines, consider performing acute rather than delayed laparoscopic cholecystectomy in patients with acute cholecystitis. B As per WSES 2020 guidelines, perform immediate laparoscopic cholecystectomy as first-line treatment in high-risk patients with acute calculous cholecystitis, recognizing that laparoscopic cholecystectomy is superior to percutaneous transhepatic gallbladder drainage in this group of patients. A Show 3 more As per SICG/WSES 2019 guidelines, perform early laparoscopic cholecystectomy in elderly patients as soon as possible, within 10 days of onset of symptoms, recognizing that earlier surgery is associated with shorter hospital stay and fewer complications. B Cholecystectomy, surgical approach: As per WSES 2020 guidelines: Perform laparoscopic or open subtotal cholecystectomy in patients with acute calculous cholecystitis if anatomic identification is difficult or the risk of iatrogenic injuries is high. B Convert from laparoscopic to open cholecystectomy in patients with acute calculous cholecystitis and any of the following: severe local inflammation https://web.pathway.md/diseases/recSrhoDrXV1gdurf 6/9 6/23/23, 1:43 AM Acute cholecystitis Pathway adhesions bleeding from the Calot's triangle suspected bile injury. B As per SICG/WSES 2019 guidelines, consider performing laparoscopic or open subtotal cholecystectomy in elderly patients with advanced inflammation, gangrenous gallbladder, and "difficult gallbladder" where anatomy is difficult to be recognized and main bile duct injuries are highly probable. C Show 2 more As per TG 2018 guidelines, view intraoperative findings as appropriate indicators of surgical difficulty in laparoscopic cholecystectomy for acute cholecystitis. B Show 4 more Cholecystectomy (intraoperative bile and tissue cultures): consider obtaining bile and tissue cultures if perforation, emphysematous changes, or necrosis of gallbladder are noted during cholecystectomy. C Cholecystectomy (management of postoperative leaks): perform ERCP as first-line therapy for postoperative biliary leaks. A Gallbladder drainage, indications: As per DSS 2022 guidelines, consider performing percutaneous transhepatic gallbladder drainage as an interval procedure until delayed laparoscopic cholecystectomy in patients with acute cholecystitis and temporary contraindications to surgery. C As per WSES 2020 guidelines, perform gallbladder drainage in patients with acute calculous cholecystitis not suitable for surgery with an intention to control sepsis. B As per SICG/WSES 2019 guidelines: Consider performing percutaneous cholecystostomy for the treatment of elderly patients (> 65 years old) with acute calculous cholecystitis and American Society of Anesthesiologist III/IV, performance status 3 to 4, or septic shock, deemed unfit for surgery. C Consider performing percutaneous cholecystostomy as a bridge to cholecystectomy if medical therapy failed in acutely ill (high-risk) elderly patients deemed unfit for surgery, in order to convert them into a moderate risk patient, more suitable for surgery. C Gallbladder drainage, surgical technique: As per WSES 2020 guidelines, consider performing endoscopic transpapillary gallbladder drainage or endoscopic US-guided transmural gallbladder drainage as alternative options to percutaneous transhepatic gallbladder drainage in patients with acute calculous cholecystitis not suitable for surgery, if performed in high-volume centers by skilled endoscopists. B Show 2 more As per SICG/WSES 2019 guidelines, prefer percutaneous transhepatic approach for percutaneous cholecystostomy in elderly patients with acute cholecystitis. B As per TG 2018 guidelines, perform percutaneous transhepatic gallbladder drainage as standard drainage method in surgically high-risk patients with acute cholecystitis. B https://web.pathway.md/diseases/recSrhoDrXV1gdurf 7/9 6/23/23, 1:43 AM Acute cholecystitis Pathway Show 2 more Gallbladder drainage, timing for removal: As per WSES 2020 guidelines, remove metal stents within 4 weeks, if US-guided transmural gallbladder drainage was performed using metal stents, to avoid food impaction and subsequent high risk of acute calculous cholecystitis recurrence. B As per SICG/WSES 2019 guidelines, remove percutaneous cholecystostomy catheter 4-6 weeks after placement in elderly patients, if a cholangiography performed 2-3 weeks after percutaneous cholecystostomy demonstrated biliary tree patency. B Management of choledocholithiasis: remove common bile duct stones preoperatively, intraoperatively, or postoperatively, depending on local expertise and availability. A Likelihood Ratios Pertinent positives The following findings increase the probability of acute cholecystitis in adults. -1 Finding LR+ Value Presence of clinical impression of acute cholecystitis 25-30 Presence of findings of acute cholecystitis 2.7 (1.7-4.1) Presence of RUQ tenderness 1.6 (1.0-2.5) Pertinent negatives The following findings decrease the probability of acute cholecystitis in adults. -1 Finding LR- Value Absence of findings of acute cholecystitis 0.13 (0.04-0.39) Absence of Murphy's sign 0.5 (0.2-1.0) References 1. Harumi Gomi, Joseph S Solomkin, David Schlossberg et al. Tokyo Guidelines 2018 antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018 Jan;25 1 3 16. Open 2. Pisano M, Ceresoli M, Cimbanassi S et al. 2017 WSES and SICG guidelines on acute calculous cholecystitis in elderly population. World J Emerg Surg. 2019 Mar 4;14 10. Open 3. ASGE Standards of Practice Committee, Krishnavel V Chathadi, Vinay Chandrasekhara et al. The role of ERCP in benign diseases of the biliary tract. Gastrointest Endosc. 2015 Apr;81 4 795 803. Open 4. Michele Pisano, Niccol Allievi, Kurinchi Gurusamy et al. 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World J Emerg Surg. 2020; 15 61. Open https://web.pathway.md/diseases/recSrhoDrXV1gdurf 8/9 6/23/23, 1:43 AM Acute cholecystitis Pathway 5. Yasuhisa Mori, Takao Itoi, Todd H Baron et al. Tokyo Guidelines 2018 management strategies for gallbladder drainage in patients with acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25 1 87 95. Open 6. EASL. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016 Jul;65 1 146 181. Open 7. Masamichi Yokoe, Jiro Hata, Tadahiro Takada et al. Tokyo Guidelines 2018 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25 1 41 54. Open 8. Go Wakabayashi, Yukio Iwashita, Taizo Hibi et al. Tokyo Guidelines 2018 surgical management of acute cholecystitis: safe steps in laparoscopic cholecystectomy for acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25 1 73 86. Open 9. Daniel M nsted Shabanzadeh, Dorthe Wiinholdt Christensen, Caroline Ewertsen et al. National clinical practice guidelines for the treatment of symptomatic gallstone disease: 2021 recommendations from the Danish Surgical Society. Scand J Surg. 2022 Aug 24;14574969221111027. Open 10. Lawrence M Knab, Anne-Marie Boller, David M Mahvi. Cholecystitis. 2014 Apr;94 2 455 70.2014 Apr;94 2 455 70. Open 11. Adrian A Indar, Ian J Beckingham. Acute cholecystitis. 2002 Sep 21;325 7365 639 43.2002 Sep 21;325 7365 639 43. Open 12. Valerie Halpin. Acute cholecystitis. 2014 Aug 20;2014 0411.2014 Aug 20;2014 0411. Open 13. Ansaloni L, Pisano M, Coccolini F et al. 2016 WSES guidelines on acute calculous cholecystitis. World J Emerg Surg. 2016 Jun 14;11 25. Open 14. Pisano M, Ceresoli M, Cimbanassi S et al. 2017 WSES and SICG guidelines on acute calcolous cholecystitis in elderly population. World J Emerg Surg. 2019 Mar 4;14 10. Open 15. Society of American Gastrointestinal and Endoscopic Surgeons. Choosing Wisely SAGES recommendations. Choosing Wisely. 2019. Open 16. Robert L Trowbridge, Nicole K Rutkowski, Kaveh G Shojania. Does this patient have acute cholecystitis?. JAMA. 2003 Jan 1;289 1 80 6. Open 17. Masamichi Yokoe, Jiro Hata, Tadahiro Takada et al. Tokyo Guidelines 2018 diagnostic criteria and severity grading of acute cholecystitis (with videos). J Hepatobiliary Pancreat Sci. 2018 Jan;25 1 41 54. Open 18. Kohji Okamoto, Kenji Suzuki, Tadahiro Takada et al. Tokyo Guidelines 2018 flowchart for the management of acute cholecystitis. J Hepatobiliary Pancreat Sci. 2018 Jan;25 1 55 72. Open 19. Expert Panel on Gastrointestinal Imaging:, Christine M Peterson, Michelle M McNamara et al. ACR Appropriateness Criteria Right Upper Quadrant Pain. J Am Coll Radiol. 2019 May;16 5S S235 S243. Open 20. Susumu Tazuma, Michiaki Unno, Yoshinori Igarashi et al. Evidence-based clinical practice guidelines for cholelithiasis 2016. J Gastroenterol. 2017 Mar;52 3 276 300. Open 21. Italian Association for the Study of the Liver AISF , Italian Association for the Study of the Liver AISF. AISF position paper on liver disease and pregnancy. Dig Liver Dis. 2016 Feb;48 2 120 37. Open https://web.pathway.md/diseases/recSrhoDrXV1gdurf 9/9