Acute Cholecystitis and Cholangitis in adults

Publication: 01/04/2009

Next review: 09/01/2026

Clinical Guideline

CURRENT

ID: 1684

Approved By: Improving Antimicrobial Prescribing Group

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Update on aztreonam injection shortage - now only restricted outside of CF and UTI (protected antibiotic codes no longer required for these indications). See alternatives - 22 August 2018

Diagnosis and Management of Acute Cholecystitis and Cholangitis in adults

Summary
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Background
Clinical Diagnosis
Investigation
Treatment

Non-Antimicrobial Treatment
Empirical Antimicrobial Treatment
Duration of Treatment
Switch to oral agent(s)

Summary
Acute Cholecystitis and Cholangitis in adults

Criteria for use of guidelines

Patients presenting with clinical features consistent with acute cholecystitis or cholangitis.

Diagnosis
See tables 1 & 3

Assessment of severity
See tables 2 & 4

Investigations

FBC, U&E’s, LFT’s, clotting profile (INR) and amylase.
Blood cultures (Please see LTHT guidance for blood culture sampling in adults)
Arterial blood gas (if evidence of acute abdomen or sepsis)
Consider urgent imaging in the form of Ultrasound as the primary radiological test. MRCP should be second-line if there is evidence of common bile duct (CBD) obstruction on Ultrasound and LFTs are not improving
Abdominal radiograph is not useful for the diagnosis of Cholecystitis or Cholangitis
Bile fluid (if drained or aspirated) should be sent for M, C & S

Non-Antimicrobial Management

ABC resuscitation
Analgesia - oral or parenteral
Consider parenteral vitamin K for patients with cholangitis or obstructive jaundice, even if INR is normal, as it can take up to 3 days for the INR to become raised in the presence of obstructive jaundice
Senior surgical assessment of disease severity
Consider invasive monitoring and level 2 or 3 care for severe cases

Initial Antimicrobial Management
Tables 5 & 6

Background

Approximately 5%–15% of people in developed countries have gallstones
1% to 3% of patients with gallstones will develop severe gallstone diseases annually [C]
90% of cases of acute cholecystitis are due to gallbladder calculi [C]
10% of cases of acute cholecystitis are 'acalculous' [C]
9% of admissions with gallstone disease have acute cholangitis [C]
80% of cases of acute cholangitis are due to gallstones [C]

Clinical Diagnosis

Table 1. Diagnostic Criteria for Acute Cholangitis (Wada et. al. 2007)
A. Clinical context and clinical manifestations	History of biliary disease Fever and/or rigors Jaundice Abdominal pain (RUQ or upper abdominal)
B. Laboratory data	Evidence of inflammatory response (elevated WBC, CRP) Abnormal liver function tests (Increased serum ALP and ALT levels)
C. Imaging findings	Biliary dilatation, or evidence of an aetiology (stricture, stone, stent etc)
Suspected diagnosis	Two or more items in A
Definite diagnosis	(1) Charcot’s triad (2 + 3 + 4) (2) Two or more items in A + both items in B and item C

Table 2. Definitions of severity assessment criteria for Acute Cholangitis (modified from Wada et. al. 2007)

Mild/Moderate acute cholangitis
Acute cholangitis, which responds to the initial medical treatment (general supportive care and antibiotics) and may be accompanied by a SIRS response but is not accompanied by organ dysfunction.
Severe acute cholangitis
Acute cholangitis that is associated with Severe Sepsis/SIRS and the onset of dysfunction at least in any one of the following organs/systems. If criteria for Severe Sepsis are met consider as severe cholangitis.

Cardiovascular system: Hypotension
Nervous system: Disturbance of consciousness
Respiratory system: PaO2/FiO2 ratio < 300
Kidney: Serum creatinine > 180 umol/L
Liver: PT-INR > 1.5
Haematological system: Platelet count < 100 10*9/L

Table 3. Diagnostic Criteria for Acute Cholecystitis (calculous and acalculous) (Note: acute hepatitis, other acute abdominal diseases, and chronic cholecystitis should be excluded) (Hirota et.al. 2007)
A. Local signs of inflammation etc.	Murphy’s sign RUQ pain/tenderness/mass
B. Systemic signs of inflammation etc.	Fever Elevated WBC count or CRP
C. Imaging findings	imaging findings characteristic of acute cholecystitis
Definite diagnosis	One item in A and one item in B are positive C confirms the diagnosis when acute cholecystitis is suspected clinically

Table 4. Definitions of severity assessment criteria for Acute Cholecystitis (calculous and acalculous)
(modified from Hirota et.al. 2007)

Mild/Moderate

Acute cholecystitis in a healthy patient with no organ dysfunction and mild/moderate inflammatory changes around the gallbladder, making cholecystectomy a safe and low-risk operative procedure in experienced hands (NICE Guidelines 2014)

Severe

Acute cholecystitis is accompanied by dysfunctions in any one of the following organs/systems. If criteria for Severe Sepsis are met consider as severe cholecystitis.

Cardiovascular dysfunction (hypotension)
Neurological dysfunction (decreased level of consciousness)
Respiratory dysfunction (PaO2/FiO2 ratio <300)
Renal dysfunction (oliguria, creatinine >180 umol/L)
Hepatic dysfunction (PT-INR >1.5)
Hematological dysfunction (platelet count <100 10*9/L)

Investigation

FBC, U&E’s, LFT’s, clotting profile (INR) and amylase [C]
Blood cultures (Please see LTHT guidance for blood culture sampling in adults) [C]
Arterial Blood Gas (if evidence of acute abdomen, organ failure or sepsis) [D]
Consider urgent imaging - USS biliary tract +/- CT abdomen/pelvis (especially if concurrent acute pancreatitis); consider MRCP with Radiologist if LFTs do not improve and evidence of biliary obstruction on Ultrasound.
Abdominal radiograph is not useful for the diagnosis of Cholecystitis or Cholangitis. Alternative imaging e.g. Ultrasound, should be the primary radiological test when alternative diagnoses e.g. perforations, are not considered likely [D].
Bile fluid (if drained or aspirated) should be sent for M, C & S [C]

Treatment

Non-Antimicrobial Treatment

General management

ABC resuscitation
Analgesia - oral or parenteral
Consider parenteral vitamin K for patients with cholangitis and a raised INR, or in the presence of obstructive jaundice
Senior surgical assessment of disease severity
Consider invasive monitoring and level 2 or 3 care for moderate-severe cases [C]

Calculous cholecystitis

Mild/moderate cholecystitis

Early (within a week) laparoscopic cholecystectomy is considered safe and effective in the hands of experienced laparoscopic surgeons [A], and is currently the NICE guidance for acute cholecystitis (NICE Guidance for Gallstones, October 2014)
In the elderly aim for elective or early laparoscopic cholecystectomy unless comorbidity precludes surgery then cholecystostomy and observation may be appropriate [C]

Severe cholecystitis

Early urgent laparoscopic cholecystectomy recommended if history is less than 7 days duration and only for experienced laparoscopic surgeons otherwise morbidity is greater [C]
Cholecystostomy recommended in the more severely ill patient with surgery if percutaneous drainage fails [C]

Acalculous cholecystitis

Diagnosis is more difficult than for calculous cholecystitis; morbidity and mortality is also higher [C]
Bear in mind underlying condition of patient and aim for percutaneous drainage or laparoscopic cholecystectomy rather than a conservative approach [C]

Acute cholangitis

Mild cholecystitis

Conservative (medical) treatment and confirmation of biliary obstruction by USS +/- MRCP followed by endoscopic biliary drainage (ERCP) [A]
Urgent endoscopic biliary drainage (ERCP) if deterioration with conservative measures [A]
Percutaneous biliary drainage if endoscopic therapy unsuccessful or expertise not available [B]
Elective laparoscopic cholecystectomy following resolution of cholecystitis in cases caused by gallstones unless the patient is unfit or declines surgery [B]

Moderate/severe cholecystitis

Urgent endoscopic or percutaneous biliary drainage with concurrent resuscitation/organ support [A]
Elective laparoscopic cholecystectomy following resolution of cholecystitis in cases caused by gallstones unless the patient is unfit or declines surgery [B]

Empirical Antimicrobial Treatment

Table 5: Initial Treatment of Severe cholecystitis or cholangitis with severe sepsis
Severity/Sepsis assessment
Initial Treatment of Severe cholecystitis or cholangitis with severe sepsis	See Severe Sepsis Guideline

Table 6: Initial Treatment of Mild/Moderate cholecystitis or cholangitis with non-severe sepsis
Severity/Sepsis assessment	No penicillin allergy		Penicillin allergy AND previously tolerated cephalosporins	Penicillin allergy AND NOT previously tolerated cephalosporins
	Age ≤ 80 years old	Age >80 years old
Initial Treatment of Mild/Moderate cholecystitis or cholangitis with non-severe sepsis	IV Co-amoxiclav 1.2 grams 8-hourly	IV Piperacillin/tazobactam 4.5 grams 8-hourly	IV Cefuroxime 1.5g 8-hourly plus PO Metronidazole 400mg 8-hourly*	Ciprofloxacin 400mg IV 12-hourly plus PO Metronidazole 400mg 8-hourly* [Evidence Level C]
* If unable to tolerate PO Metronidazole can give IV Metronidazole 500mg 8-hourly

Duration of Treatment

Cholangitis:
Mild cholecystitis: 3 day course if clinically improved. Patients should be switched to oral medicines as soon as they meet IV to oral switch criteria
Moderate/Severe cholecystitis: 5-7 days then review with clinical progress and inflammatory markers [C] Patients should be switched to oral medicines as soon as they meet IV to oral switch criteria

Cholecystitis:
5-7 days then review with clinical progress and inflammatory markers [D] Patients should be switched to oral medicines as soon as they meet IV to oral switch criteria

Switch to oral agent(s)

Table 7: Oral Switch Treatment
	No penicillin allergy	Penicillin allergy AND previously tolerated cephalosporins	Allergy to penicillins and NOT previously tolerated cephalosporins
Oral switch Treatment	PO Co-amoxiclav 625mg 8-hourly	PO Cefalexin 500mg 6-hourly plus PO Metronidazole 400mg 8-hourly	PO Ciprofloxacin 500mg 12-hourly plus PO Metronidazole 400mg 8-hourly

Patients should be switched to oral medicines as soon as they meet IV to oral switch criteria

Provenance

Record:	1684
Objective:	To improve the diagnosis and management of patients presenting with clinical features consistent with acute cholecystitis or cholangitis. To provide evidence-based recommendations for appropriate investigation of acute cholecystitis or cholangitis. To provide evidence-based recommendations for appropriate empirical or directed antimicrobial therapy of acute cholecystitis or cholangitis. To recommend appropriate dose, route of administration and duration of antimicrobial agents. To advise in the event of antimicrobial allergy. To set-out criteria for referral to specialists.
Clinical condition:	Acute cholecystitis or cholangitis
Target patient group:	Patients presenting with clinical features consistent with acute cholecystitis or cholangitis
Target professional group(s):	Secondary Care Doctors Secondary Care Nurses Pharmacists
Adapted from:

Evidence base

Evidence base

Yoshida M. Antimicrobial therapy for acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:83-90.
Yasuda H. Unusual cases of acute cholecystitis and cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:98-113.
Yamashita Y. Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:91-97.
Wada K. Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:52-58.
Tsuyuguchi T. Techniques of biliary drainage for acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:46-51.
Tsuyuguchi T. Techniques of biliary drainage for acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:35-45.
Tanaka A. Antimicrobial therapy for acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:59-67.
Takada T. Background: Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Surg 2007;14:1-10.
Strasberg SM. Acute Calculous Cholecystitis. T h e new engl and journa l o f medicine 2008;358:2804-11.
Sekimoto M. Need for criteria for the diagnosis and severity assessment of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:11-14.
Nagino M. Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:69-77.
Miura F. Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:27-34.
Mayumi T. Results of the Tokyo Consensus Meeting Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:114-21.
Kimura Y. Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:15-26.
Iheanacho I. What if it’s acute cholangitis? Drug and Therapeutics Bulletin 2005;43(8):62-64.
Hirota M. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:78-82.
NICE. October 2014. Gallstone Disease. Clinical Guideline 188 [online] London, NICE Available from the World Wide Web. http://www.nice.org.uk/guidance/cg188/resources/guidance-gallstone-disease-pdf

Approved By

Improving Antimicrobial Prescribing Group

Document history

LHP version 2.0

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