Acute Cholecystitis and Cholangitis in adults

Publication: 01/04/2009  --
Last review: 13/02/2020  
Next review: 13/02/2023  
Clinical Guideline
CURRENT 
ID: 1684 
Approved By: Improving Antimicrobial Prescribing Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2020  

 

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
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

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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]

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Clinical Diagnosis

Table 1. Diagnostic Criteria for Acute Cholangitis (Wada et. al. 2007)

A. Clinical context and clinical manifestations

  1. History of biliary disease
  2. Fever and/or rigors
  3. Jaundice
  4. Abdominal pain (RUQ or upper abdominal)

B. Laboratory data

  1. Evidence of inflammatory response (elevated WBC, CRP)
  2. Abnormal liver function tests (Increased serum ALP and ALT levels)

C. Imaging findings

  1. 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.

  1. Cardiovascular system: Hypotension
  2. Nervous system: Disturbance of consciousness
  3. Respiratory system: PaO2/FiO2 ratio < 300
  4. Kidney: Serum creatinine > 180 umol/L
  5. Liver: PT-INR > 1.5
  6. 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.

  1. Murphy’s sign
  2. RUQ pain/tenderness/mass

B. Systemic signs of inflammation etc.

  1. Fever
  2. Elevated WBC count or CRP

C. Imaging findings

  1. imaging findings characteristic of acute cholecystitis

Definite diagnosis

  1. One item in A and one item in B are positive
  2. 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.

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

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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]

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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]

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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 electronic Medicines Compendium information on Co-amoxiclav 1.2 grams 8-hourly

IV Piperacillin/tazobactam electronic Medicines Compendium information on Piperacillin/tazobactam 4.5 grams 8-hourly

IV Cefuroxime electronic Medicines Compendium information on Cefuroxime 1.5g 8-hourly plus PO Metronidazole electronic Medicines Compendium information on Metronidazole 400mg 8-hourly*

IV Aztreonam electronic Medicines Compendium information on Aztreonam 1g 8-hourly plus PO Metronidazole electronic Medicines Compendium information on Metronidazole 400mg 8-hourly*
[Evidence Level C]

* If unable to tolerate PO Metronidazole electronic Medicines Compendium information on Metronidazole can give IV Metronidazole electronic Medicines Compendium information on Metronidazole 500mg 8-hourly

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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

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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 electronic Medicines Compendium information on Co-amoxiclav 625mg 8-hourly

PO Cefalexin electronic Medicines Compendium information on Cefalexin 500mg 6-hourly plus PO Metronidazole electronic Medicines Compendium information on Metronidazole 400mg 8-hourly

PO Ciprofloxacin electronic Medicines Compendium information on Ciprofloxacin 500mg 12-hourly plus PO Metronidazole electronic Medicines Compendium information on Metronidazole 400mg 8-hourly

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

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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

  1. Yoshida M. Antimicrobial therapy for acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:83-90.
  2. Yasuda H. Unusual cases of acute cholecystitis and cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:98-113.
  3. Yamashita Y. Surgical treatment of patients with acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:91-97.
  4. Wada K. Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:52-58.
  5. Tsuyuguchi T. Techniques of biliary drainage for acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:46-51.
  6. Tsuyuguchi T. Techniques of biliary drainage for acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:35-45.
  7. Tanaka A. Antimicrobial therapy for acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:59-67.
  8. Takada T. Background: Tokyo Guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Surg 2007;14:1-10.
  9. Strasberg SM. Acute Calculous Cholecystitis. T h e new engl and journa l o f medicine 2008;358:2804-11.
  10. 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.
  11. Nagino M. Methods and timing of biliary drainage for acute cholangitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:69-77.
  12. Miura F. Flowcharts for the diagnosis and treatment of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:27-34.
  13. Mayumi T. Results of the Tokyo Consensus Meeting Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:114-21.
  14. Kimura Y. Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:15-26.
  15. Iheanacho I. What if it’s acute cholangitis? Drug and Therapeutics Bulletin 2005;43(8):62-64.
  16. Hirota M. Diagnostic criteria and severity assessment of acute cholecystitis: Tokyo Guidelines. J Hepatobiliary Pancreat Surg 2007;14:78-82.
  17. 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

Related information

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