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CDHB

Acute Cholecystitis

Causes, History and Examination - Acute Cholecystitis

• The most frequent cause is bacterial infection secondary to gallstones. It may also occur in malnutrition including anorexia nervosa.
• A history of biliary colic may be obtained, although an attack of acute cholecystitis may occur without prior biliary tract disease.
• Pain and tenderness in the right hypochondrium. Pain may be referred to the right shoulder. Fever and jaundice may be present.

Investigations - Acute Cholecystitis

• CBC + diff, INR, APTT, Na, K, creatinine, LFTs, amylase or lipase, CRP.
• Upper abdominal USS.

Then review.

Management

• If no cholecystitis, consider other causes and investigate.

If cholecystitis confirmed:

• IV antibiotics: IV amoxicillin 1 g q6h, IV gentamicin (refer to the gentamicin/tobramycin dosing guidelines in the Pink Book), and IV metronidazole 500 mg q8h.
• Nil by mouth and IV fluids.
• 4 hourly observations, fluid balance chart.
• Analgesia.
• VTE prophylaxis (e.g., enoxaparin).

Acute Laparoscopic Cholecystectomy

• Book for surgery after discussion with Surgeon.
• Check ready for surgery, i.e. consent, CXR, ECG, laboratory results.
• Post-operative care:
  • Routine post-op observation.
  • Analgesia.
  • IV fluids until drinking.
  • Commence diet as tolerated.
  • VTE prophylaxis.
  • Discuss with the Surgeon whether to change from IV to oral antibiotics.
  • Discharge home with appropriate script for analgesia, discharge summary.
  • Follow-up with GP unless Surgeon requests to see in clinic.

Acute Open Cholecystectomy

• As above but post-operative analgesia may include wound catheters, patient-controlled analgesia (PCA).

Conservative treatment

• Once settled, discharge on oral analgesia and antibiotics, usually amoxicillin/ clavulanate 625 mg PO TDS.
• Book elective laparoscopic cholecystectomy.

Topic Code: 66065