Acute cholecystitis; Calculous and Acalculous

Scenario: Patients usually present with steady and severe right upper quadrant pain, fever, nausea, vomiting etc. They could have diagnosed history of gallstones but may not.

ER:

Routine labs, EKG, Chest x ray

Abdominal imaging -US vs CT of Abdomen and Pelvis

A positive Murphy’s sign on physical examination

IV antibiotics first dose after diagnosis

NPO status

General surgery consult if imaging shows acute cholecystitis for Cholecystectomy as cholecystectomy is the gold-standard treatment for patients with acute calculous cholecystitis. They usually admit under observation status as the patient can be discharged the next day if patient gets Laparoscopic Cholecystectomy soon enough.

Antibiotics are generally stopped a day after surgery in those patients who have cholecystectomy.

If patient gets open cholecystectomy or was found to have gangrene or perforation and needs antibiotics, patient could potentially be upgraded to inpatient status from observation status.

Surgeons usually do intraoperative cholangiography to look for Common Bile Duct stones.

If diagnosis in not clear but signs and symptoms point towards Cholecystitis, ER physicians or surgeons may order HIDA scan to look for patency of Cystic duct. If patent then it’s probably not cholecystitis.

Medical consult if poor surgical candidate but has acute cholecystitis for medical management.

Hospitalist:

Admit to Med-Surgical floor for non operative management due to high surgical risk

IV fluids

IV antibiotics- Ciprofloxacin 400mg IV Q 12hrs plus Metronidazole 500mg IV Q8 hrs is usual regimen. You can replace Ciprofloxacin with a Cephalosporin like Ceftriaxone or Cefazolin or Cefotaxime or Cefuroxime if patient has allergy to Cipro.

NPO

IV Ondansetron 4mg q 4-6 hrs for nausea

Pain control with IV Toradol 15-30mg or IV Morphine 1-2mg every 3-6hrs depending on amount of pain.

IR consult for drain placement for Percutaneous transhepatic drainage. The drain could stay in for a few weeks.

These high risk, non-operatively managed patients may need antibiotics IV or PO for a few days depending on the situation.

All the management regarding non operative management will be guided by a general surgeon who has seen the patient already before we admit.

If the patient is found to have Common Bile Duct [CBD] stone on admission in the imaging, Gastroenterologist consult could be obtained to do Endoscopic Retrograde Cholangio-Pancreatography [ERCP] to get that stone out.

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