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Acute cholecystitis

What's new

Updated 2024 ASGE guidelines for endoscopic gallbladder drainage in acute cholecystitis .

Background

Overview

Definition
Acute cholecystitis is an inflammation of the gallbladder and is usually caused by obstruction of the cystic duct.
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Pathophysiology
Acute cholecystitis is mostly caused by gall stones or by impacted biliary sludge with or without secondary bacterial infection (E. coli, Klebsiella, and Streptococcus faecalis).
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Disease course
The inflammatory process due to obstruction of cystic duct results in acute cholecystitis, which causes clinical manifestations of persistent pain and tenderness in the RUQ, and mild jaundice. Disease progression may lead to gangrenous cholecystitis, gallbladder perforation, cholecystoenteric fistulas, gallstone ileus, and acalculous cholecystitis.
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Prognosis and risk of recurrence
In the US, the overall mortality associated with untreated complications of acute cholecystitis is approximately 20%.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of acute cholecystitis are prepared by our editorial team based on guidelines from the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES 2025,2024), the American Academy of Family Physicians (AAFP 2024), the American Society for Gastrointestinal Endoscopy (ASGE 2024,2015), the Infectious Diseases Society of America (IDSA 2024), the Danish Surgical Society ...
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Screening and diagnosis

Clinical presentation: as per AAFP 2024 guidelines, use the Murphy sign on physical examination to rule in acute cholecystitis.
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  • Diagnostic criteria

Classification and risk stratification

Severity grading and prognosis: as per IDSA 2024 guidelines, assess disease severity for risk stratification in patients with complicated intra-abdominal infections. Consider using the APACHE II as the preferred severity of illness score for risk stratification within 24 hours of hospital or ICU admission in adult patients with complicated intra-abdominal infection, if a severity of illness score is used.
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  • Risk stratification of choledocholithiasis

  • Risk stratification of elderly patients

Diagnostic investigations

General principles
As per WSES 2020 guidelines:
Consider using a combination of detailed history, complete clinical examination, laboratory tests, and imaging for the diagnosis of acute calculous cholecystitis, although recognize that the best combination is not known.
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Do not rely on a single clinical or laboratory finding to confirm or exclude acute cholecystitis.
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  • Abdominal ultrasound

  • Further imaging (general population)

  • Further imaging (elderly patients)

  • Laboratory tests (CBC and serum biochemistry)

  • Laboratory tests (blood cultures)

  • Evaluation for choledocholithiasis

Diagnostic procedures

Intra-abdominal culture: as per IDSA 2024 guidelines, consider obtaining intra-abdominal cultures to guide antimicrobial therapy in adult and pediatric patients with complicated intra-abdominal infections undergoing a procedure for source control.
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Medical management

Indications for nonoperative management
As per WSES 2020 guidelines:
Consider offering nonoperative management with antibiotics and observation in patients with acute calculous cholecystitis refusing or not suitable for surgery.
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Consider offering alternative treatment options (such as gallstone dissolution or extracorporeal shock wave lithotripsy) in patients with acute calculous cholecystitis who have failed nonoperative management and are still refusing or not suitable for surgery.
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  • Antibiotic therapy (general population)

  • Antibiotic therapy (elderly patients)

  • NSAIDs

Therapeutic procedures

Gallbladder drainage, indications: as per DSS 2022 guidelines, consider performing percutaneous transhepatic gallbladder drainage as an interval procedure until delayed laparoscopic cholecystectomy in patients with acute cholecystitis and temporary contraindications to surgery.
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  • Gallbladder drainage (technique)

  • Gallbladder drainage (timing for removal)

Perioperative care

Preoperative antibiotics: as per EASL 2016 guidelines, avoid administering routine antibiotic prophylaxis before elective laparoscopic cholecystectomy.
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  • Postoperative antibiotics

Surgical interventions

Cholecystectomy, indications: as per DSS 2022 guidelines, consider performing acute laparoscopic cholecystectomy in favor of gallbladder drainage in high-risk patients with acute cholecystitis.
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  • Cholecystectomy (timing)

  • Cholecystectomy (surgical approach)

  • Cholecystectomy (intraoperative bile and tissue cultures)

  • Cholecystectomy (management of choledocholithiasis)

  • Cholecystectomy (management of postoperative leaks)

Specific circumstances

Pregnant patients: as per IDSA 2024 guidelines, consider obtaining ultrasound or MRI as the initial diagnostic imaging in pregnant patients with suspected acute cholecystitis.
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  • Patients with reconstructed digestive tracts