Acute Cholecystitis is the acute inflammation of the gall bladder and is associated in majority of cases with gall stones (90%) and without gall stone in 10% of the cases

Pathogenesis

Calculous - Stone causing obstruction of the Hartmann’s pouch or cystic duct.

Acalculous – Common in patients who have undergone major trauma, burn, sepsis. Causative bacteria- E. Coli (most common), Klebsiella, Pseudomonas, Proteus, Streptococcus Faecalis, Salmonella, Clostridium welchii.

Symptoms

·  Right upper quadrant or epigastric pain which may radiate to the back

·  Pain is often dull and constant, may be colicky

·  There may be dyspepsia, flatulence, intolerance to fatty food

·  Biliary colic presents as severe right upper quadrant pain that is associated with nausea and vomiting and may radiate to the chest, may last for a few minutes to several hours. Pain starts at night, awakening the patient.

Signs

·  Fever (may be present)

·  Tenderness – Right upper quadrant. Positive Murphy’s sign

·  Palpable tender mass in right upper quadrant of abdomen (may be present)

·  Tachycardia

·  Jaundice (may be present)

Investigations

·  Haemogram– Leucocytosis, Raised CRP

·  Liver function tests - deranged

·  Blood sugar

·  Urea / Creatinine- if needed

·  Prothrombin Time

·  Chest X-ray

·  ECG

·  Echocardiogram – In selected cases

·    USG examination of abdomen – Gall bladder distended, wall thickened, oedematous, with or without pericholecystic fluid. Gall stones present in 90% of the cases. Pooled sensitivity and specificity of USG in the diagnosis of gallstones were 84

% and 99 %

·  MRCP – In case of concomitant jaundice

·  CECT abdomen – In case of complications

·  Hepatobiliaryiminodiacetic acid scan (HIDA scan) has the highest sensitivity and specificity for acute Cholecystitis, although its scarce availability, long time required to perform the test, and exposure to ionizing radiation limit its use (LoE 2 GoRB) Diagnosis Combining clinical, laboratory and imaging investigations is recommended, although the best combination is not yet known (LoE 4 GoRC) Differential

Diagnosis

Common

·  Acute appendicitis

·  Perforated peptic ulcer

·  Acute pancreatitis

Uncommon

·  Acute pyelonephritis

·  Acute myocardial infarction

·  Pneumonia – Right lower lobe

Complications

·  Mucocele

·  Empyema of the gall bladder

·  Perforation

·  Obstructive Jaundice

·  Acute Pancreatitis

·  Acute Cholangitis

·  Intestinal Obstruction due to Gall Stone Ileus

Risk Stratification

Patient’s age above 80 in ACC is a risk factor for worse clinical behaviour, morbidity and mortality (LoE 3 GoR B) The co-existence of diabetes mellitus does not contraindicate urgent surgery but must be reconsidered as a part of the overall patient comorbidity (LoE 3 GoR C) Currently, there is no evidence of any scores in identifying patient’s risk in surgery for ACC

Treatment Conservative treatment

Nil per mouth, IV fluid, analgesics, broad spectrum antibiotics – effective against gram negative aerobes (E.g.- Cephazolin, Cefuroxime, Gentamicin), regular monitoring of the temperature, pulse and other physical signs of the patient to assess the response to the conservative treatment.

Once the pain has subsided, and the temperature and pulse have become normal, the patient can be fed orally and be sent home and kept on regular follow up, and taken up for cholecystectomy after 3 to 6 weeks (Delayed laparoscopic cholecystectomy)

Types of Surgical Approach- -In ACC, a laparoscopic approach should initially be attempted except in case of absolute anaesthesiology contraindications or septic shock (LoE 2 GoR B) –

Laparoscopic cholecystectomy for ACC is safe, feasible, with a low complication rate and associated with shortened hospital stay (LoE 1 GoR A)

-  Among high-risk patients, in those with Child A & B cirrhosis, advanced age

>80, or pregnant women, laparoscopic cholecystectomy for ACC is feasible and safe (LoE 3 GoR C)

-  Laparoscopic or open subtotal cholecystectomy is a valid option for advanced inflammation, gangrenous gallbladder, or any setting of the “difficult gallbladder” where anatomy is difficult to recognize and main bile duct injuries are more likely (LoE 2 GoR A)

-  In case of local severe inflammation, adhesions, bleeding in Calot’s triangle or suspected bile duct injury, conversion to open surgery should be strongly considered. (LoE 3 GoR B)

Timing of Surgery

·   Early laparoscopic cholecystectomy is preferable to delayed laparoscopic cholecystectomy in patients with Acute Cholecystitis as long as it is completed within 3 days of onset of symptoms (Level 1 Evidence; Grade A recommendation)

·  Laparoscopic cholecystectomy should not be offered for patients beyond 10 days from the onset of symptoms unless symptoms suggestive of worsening peritonitis or sepsis warrant an emergency surgical intervention. In people with more than 10 days of symptoms, delaying cholecystectomy for 45 days is better than immediate surgery (LoE 2 GoR B)

Associated common bile duct stone: suspicion and diagnosis at the presentation

·     Elevation of liver biochemical enzymes and/or bilirubin levels is not sufficient to identify ACC patients with choledocholithiasis and further diagnostic tests are needed. (LoE 2 GoR B)

·      At AUS, the visualization of CBDS is a very strong predictor of choledocholithiasis. (LoE 5 GoR D). Indirect signs of stone presence such as increased diameter of common bile duct are not sufficient to identify ACC patients with choledocholithiasis and further diagnostic tests are needed. (LoE 1 GoR A)

·      Liver biochemical tests, including ALT, AST bilirubin, ALP, gamma glutamyltransferase (GGT), AUS should be performed in all patients with ACC to assess the risk for CBS. (LoE 2 GoR B)

·  Common bile duct stone risk should be stratified according to the proposed classification, modified from the American Society of Gastrointestinal Endoscopy and the Society of American Gastrointestinal Endoscopic Surgeon Guidelines (LoE 5 GoR D)

·     Patients with moderate risk for choledocholithiasis should undergo preoperative MRCP, EUS, intraoperative cholangiography, or Laparoscopic ultrasound depending on the local expertise and availability. (LoE 1 GoR A)

·  Patients with high risk for choledocholithiasis should undergo preoperative ERCP, intraoperative cholangiography, Laparoscopic ultrasound, depending on the local expertise and the availability of the technique. (LoE 1 GoR A)

·  CBDS could be removed preoperatively, intraoperatively, or postoperatively according to the local expertise and the availability of the technique. (LoE 1 GoR A)

Alternative treatments for high-risk patients

·       Gallbladder drainage, together with antibiotics, converts a septic Cholecystitis into a non-septic condition; however, the level of evidence is poor (LoE 4, GoR C)

·   Among standardized gallbladder drainage techniques percutaneous trans hepatic gallbladder drainage (PTGBD) is generally recognized as the preferred technique due to the ease and the reduced costs. (LoE 4, GoR C)

·  PC could be considered as a possible alternative to surgery after the failure of conservative treatment in a small subset of patients unfit for emergency surgery due to their severe comorbidities (LoE 2 GoR B)

·    Delayed laparoscopic cholecystectomy could be offered to patients after reduction of operative and anaesthesiology related risks to reduce further hospitalization (LoE 5 GoR D) Post-

Operative Care

Antibiotic Therapy- - Patients with uncomplicated Cholecystitis can be treated without post-operative antibiotics when the focus of infection is controlled by cholecystectomy. (LoE 1 GoR B)

-   In complicated acute Cholecystitis, the antimicrobial regimens depend on presumed pathogens involved and risk factors for major resistance patterns. (LoE 3 GoR B)

-   The results of microbiological analysis are helpful in designing targeted therapeutic strategies for individual patients to customize antibiotic treatment and ensure adequate antimicrobial coverage in patients with complicated Cholecystitis and at high risk for antimicrobial resistance. (LoE 3 GoR C)

Referral Criteria

ICU care may be needed in patients who present late with severe sepsis and have other systemic illnesses. Medico legal Issues

·  Failure to diagnose and institute immediate proper treatment

Who does what? Surgeon

-  Establishing the diagnosis and working up the patient

-  Follow the abovementioned treatment algorithm

-  Post-operative care and follow up

Anaesthetist-Pre-Anaesthetic work up

-   Anesthetizing patient during surgery and post op management in critical patients

Nurse - Pre, Intra and Post op care

Technician

-Pre op equipment and drugs to be checked and kept ready

-  Assist the anaesthetist in the OT

-  Assist the surgeon, positioning of patient

Human Resources Drugs/Consumables Equipment

1.   Surgeon – 1

2.   Medical Officer / Assistant Surgeon – 1

3.   Anaesthetist – 1

4.   Pathologist – 1------ Services from outside can be availed

5.   Staff Nurse – 1

6.   Technician – 1

7.   Nursing Orderly – 1

8.   Cleaning staff-1

Investigations

1.   Hemogram

2.   Blood Sugar

3.   Renal Function Test - in selected cases

4.   LFT

5.   S. Electrolytes in selected cases

6.   USG 7. ECG

8.   Echocardiogram – in selected cases

9.   X- Ray – Chest

10.   MRCP – in selected cases

11.   CECT – in selected cases

12.   HIDA scan – selected cases

13.   Histopathology- following surgery

Drugs & Consumables

1.   OT Table & lights

2.   Instrument trolley

3.   Anaesthetic Machine, instruments including endotracheal tubes & drugs

4.   Monitor

5.   Set of surgical Instruments

6.   Suction

7.   Sutures

8.   Drains

9.   Catheters

10.   Cautery – a basic set

11.   Antibiotics

12.   Analgesic

13.   I.V. Fluids

14.   Dressings

15.    If the centre has facilities for Laparoscopic Surgery, the procedure can be done laparoscopically as decided by the Surgeon.

Abbreviations

CBDS - common bile duct stones GoR - Grade of Recommendation

IOC - Intraoperative cholangiography LC- Laparoscopic cholecystectomy LoE - Level of Evidence

LUS - Laparoscopic ultrasound;

PC - Percutaneous Cholecystostomy