Choledocholithiasis

Acute calculous cholecystitis is acute inflammation of the gallbladder caused by persistent cystic duct obstruction by a gallstone.

Obstruction produces gallbladder distension, venous and lymphatic compromise, inflammatory injury and eventually secondary bacterial infection in some patients.

Progression can produce empyema, gangrenous cholecystitis, perforation, pericholecystic abscess or biliary peritonitis.

Definitive treatment in a surgically fit patient is early laparoscopic cholecystectomy during the same acute admission.

The typical presentation is persistent right upper quadrant or epigastric pain, usually lasting more than several hours, with nausea or vomiting.

Fever and local right upper quadrant tenderness are common.

Murphy sign: arrest of inspiration due to pain when the examiner palpates the right subcostal region during deep inspiration.

Older, diabetic and immunosuppressed patients may have limited fever or peritoneal signs despite advanced disease.

Severe persistent pain, high fever, sepsis or localised peritonism should raise concern for gangrene, empyema or perforation.

Jaundice requires assessment for common bile duct obstruction, Mirizzi syndrome or cholangitis.

Check full blood count, C reactive protein, renal function and liver biochemistry.

Leukocytosis and inflammatory marker elevation support the diagnosis but do not determine severity alone.

Right upper quadrant ultrasound: first line imaging; identify an obstructing gallstone with the key inflammatory features of gallbladder wall thickening, distension or pericholecystic inflammation.

If ultrasound is equivocal but clinical suspicion remains strong, hepatobiliary scintigraphy or cross sectional imaging can clarify the diagnosis.

Evaluate for common bile duct stones when bilirubin, alkaline phosphatase or duct calibre is abnormal.

Keep fasting initially, establish IV access and correct dehydration.

Provide adequate analgesia:

Paracetamol 1 g orally or IV every 6 to 8 hours, maximum 4 g daily in an adult without significant hepatic risk.

Add an NSAID when appropriate.

Start antimicrobial treatment for acute cholecystitis.

A practical community acquired regimen is:

Ceftriaxone 2 g IV every 24 hours.

Add:

Metronidazole 500 mg IV every 12 hours

when anaerobic coverage is clinically warranted, particularly with severe infection, perforation or altered biliary gastrointestinal anatomy.

For septic shock, gangrene, perforation or significant healthcare associated infection:

Piperacillin tazobactam 4.5 g IV every 8 hours by extended infusion, adjusted for renal function.

Definitive surgery

Perform laparoscopic cholecystectomy during the index admission and as early as clinically feasible after initial resuscitation. Early surgery reduces total hospitalisation and avoids recurrent gallstone complications without requiring an interval cooling off period.

During surgery, prioritise prevention of bile duct injury.

Achieve the critical view of safety before clipping or dividing structures.

If severe inflammation prevents safe identification:

• Stop unsafe dissection
• Consider a fundus first approach only when anatomy remains controllable
• Perform subtotal cholecystectomy when necessary
• Convert to open surgery when this improves safety, although conversion alone does not guarantee clearer anatomy

Subtotal cholecystectomy can be fenestrating or reconstituting according to anatomy and surgeon judgement.

High operative risk

A patient with severe acute illness who cannot safely undergo cholecystectomy may require percutaneous cholecystostomy for source control. Do not delay drainage simply to complete a prolonged failed conservative trial when the gallbladder remains the uncontrolled septic source.

Cholecystostomy is generally a bridge rather than definitive treatment in a patient who later becomes fit for cholecystectomy.

Antibiotic duration

After uncomplicated laparoscopic cholecystectomy for mild or moderate acute cholecystitis with satisfactory source control, routine postoperative antibiotics are unnecessary.

For severe cholecystitis with organ dysfunction or infection extending beyond the gallbladder, continue antibiotics according to clinical response, generally for no more than approximately 4 days after adequate source control.