Acute Cholecystitis Management (TG18 2018)

Algorithm Steps

1. ▶

   Start

   Suspected Acute Cholecystitis

   Patient with RUQ pain, fever, and/or Murphy sign. Consider if: local signs (RUQ pain/tenderness, Murphy sign) + systemic signs (fever, elevated CRP, leukocytosis) + imaging findings

   1. ◆

      Decision

      TG18 Diagnostic Criteria Met?

      A: Local signs (Murphy sign, RUQ mass/pain/tenderness) + B: Systemic inflammation (fever >38°C, CRP elevated, WBC >10,000/mm³) + C: Imaging findings (US/CT showing gallbladder wall thickening >4mm, pericholecystic fluid, gallstones). Definite: A + B + C. Suspected: A + B

      1. ◆

         Decision

         Determine TG18 Severity Grade

         Grade I (Mild): No organ dysfunction, mild inflammatory changes. Grade II (Moderate): WBC >18,000/mm³ OR palpable RUQ mass OR duration >72h OR marked local inflammation (gangrenous, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous). Grade III (Severe): Organ dysfunction in any system

         1. ●

            Action

            Grade I (Mild)

            No organ dysfunction and mild disease. Local inflammation only.

            1. ◆

               Decision

               Surgical Risk Assessment

               Assess Charlson Comorbidity Index (CCI) and ASA Physical Status (ASA-PS). Early Lap-C if CCI ≤5 AND ASA-PS ≤2

               1. ●

                  Action

                  Early Laparoscopic Cholecystectomy

                  Perform Lap-C as soon as possible, ideally within 72 hours of symptom onset. Early surgery reduces conversion rates, complications, and hospital stay.

                  1. ●

                     Action

                     Antibiotic Selection (TG18)

                     Community-acquired Grade I-II: Cefazolin or ceftriaxone. Grade II with risk factors or Grade III: Piperacillin-tazobactam, carbapenem, or cephalosporin + metronidazole. Healthcare-associated: Add vancomycin for MRSA coverage. Duration: Until cholecystectomy for uncomplicated; 4-7 days post source control for complicated.

                     1. ✓

                        Outcome

                        Cholecystectomy Completed

                        Definitive surgical management achieved. Routine postoperative care. Pathology review for gangrenous/malignancy.

                     2. ✓

                        Outcome

                        Drainage + Delayed Surgery

                        Patient stabilized with drainage. Plan interval cholecystectomy in 6-8 weeks. Follow-up imaging to confirm resolution.

               2. ●

                  Action

                  Conservative Management

                  IV fluids, bowel rest, IV antibiotics. Consider percutaneous gallbladder drainage if no improvement in 24-48h. Plan delayed Lap-C after inflammation resolves (6-8 weeks).

         2. ●

            Action

            Grade II (Moderate)

            Marked local inflammation: WBC >18,000/mm³, palpable mass, duration >72h, or local complications (gangrenous, abscess)

            1. ◆

               Decision

               Advanced Laparoscopic Skills Available?

               Assess surgical expertise and patient factors. Experienced laparoscopic surgeon at advanced center? Patient CCI and ASA-PS acceptable for surgery?

               1. ●

                  Action

                  Early Lap-C by Expert Surgeon

                  Perform Lap-C with experienced surgeon. Higher conversion risk but acceptable. Consider subtotal cholecystectomy if severe inflammation.

               2. ●

                  Action

                  Early Biliary Drainage

                  Percutaneous transhepatic gallbladder drainage (PTGBD) or endoscopic approach. Stabilize patient. Plan delayed cholecystectomy once inflammation resolves.

         3. ●

            Action

            Grade III (Severe)

            Organ dysfunction present: CV (hypotension requiring vasopressors), Neurological (decreased consciousness), Respiratory (PaO2/FiO2 <300), Renal (oliguria, Cr >2.0), Hepatic (PT-INR >1.5), Hematologic (Plt <100,000)

            1. ●

               Action

               Intensive Organ Support

               ICU admission. Aggressive resuscitation: IV fluids, vasopressors if needed, respiratory support. Initiate broad-spectrum antibiotics immediately.

               1. ●

                  Action

                  Urgent Biliary Drainage

                  PTGBD is first-line for source control. Endoscopic drainage as alternative. NOT early cholecystectomy - too high risk. Cholecystectomy only after full recovery and optimization.

               2. ⚠

                  Warning

                  ⚠️ Watch for Gangrenous Cholecystitis

                  Signs: persistent fever despite antibiotics, high WBC, gas in gallbladder wall (emphysematous), perforation on imaging. Requires urgent surgery or drainage even if Grade III. Mortality significantly increased if delayed.