Acute Cholecystitis View online at http://pier.acponline.org/physicians/diseases/d642/d642.html Module Updated: 2013-02-20 CME Expiration: 2016-02-20 Author Badri Man Shrestha, MS, MPhil, MD, FRCS Table of Contents 1. Prevention .........................................................................................................................2 2. Diagnosis ..........................................................................................................................4 3. Consultation ......................................................................................................................8 4. Hospitalization ...................................................................................................................11 5. Therapy ............................................................................................................................12 6. Patient Education ...............................................................................................................16 7. Follow-up ..........................................................................................................................17 References ............................................................................................................................19 Glossary................................................................................................................................23 Tables ...................................................................................................................................25 Figures .................................................................................................................................30 Quality Ratings: The preponderance of data supporting guidance statements are derived from: level 1 studies, which meet all of the evidence criteria for that study type; level 2 studies, which meet at least one of the evidence criteria for that study type; or level 3 studies, which meet none of the evidence criteria for that study type or are derived from expert opinion, commentary, or consensus. Study types and criteria are defined at http://smartmedicine.acponline.org/criteria.html Disclaimer: The information included herein should never be used as a substitute for clinical judgement and does not represent an official position of the American College of Physicians. Because all PIER modules are updated regularly, printed web pages or PDFs may rapidly become obsolete. Therefore, PIER users should compare the module updated date on the offical web site with any printout to ensure that the information is the most current available. CME Statement: The American College of Physicians is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing education for physicians. The American College of Physicians designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only credit commensurate with the extent of their participation in the activity. Purpose: This activity has been developed for internists to facilitate the highest quality professional work in clinical applications, teaching, consultation, or research. Upon completion of the CME activity, participants should be able to demonstrate an increase in the skills and knowledge required to maintain competence, strengthen their habits of critical inquiry and balanced judgement, and to contribute to better patient care. Disclosures: Badri Man Shrestha, MS, MPhil, MD, FRCS, current author of this module, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Deborah Korenstein, MD, FACP, Co-Editor, PIER, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. Richard B. Lynn, MD, FACP, Co-Editor, PIER, has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations. PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA. Acute Cholecystitis Top 1. Prevention Consider medical therapy and prophylactic cholecystectomy in patients with symptomatic gallstones. 1.1 Consider UDCA to dissolve symptomatic cholesterol gallstones. Recommendations • Consider prescribing oral UDCA, 8 to 12 mg/kg·d. Evidence • In a meta-analysis of trials published from 1966 to 1992 comprising 1949 patients, complete dissolution was achieved in 18.2% of patients with CDCA, 37.3% with UDCA, and 62.8% with combination therapy (1). • A double-blind, randomized, controlled study showed up to 55% partial dissolution and up to 29% complete dissolution of radiolucent gallstones with UDCA. Dissolution was most effective in stones <5 mm in diameter (2). • A randomized, double-blind study showed that in patients treated with UDCA, there was a significant reduction in biliary cholesterol concentration, formation of cholesterol crystals, and bile viscosity (3). • A 2008 meta-analysis of five randomized, controlled trials including 521 patients showed significant reduction of gallstone formation after bariatric surgery (RR, 0.43 [CI, 0.22 to 0.83]), with 8.8% of those taking UDCA developing gallstones compared with 27.7% of those taking placebo (P=0.01) (4). • In a prospective study of 1059 patients who had laparoscopic cholecystectomy for symptomatic gallstones, risk factors for developing acute cholecystitis were analyzed. Age older than 60 years, male sex, the presence of cardiovascular disease, the presence of diabetes mellitus, and a history of cerebrovascular accident (ischemic stroke or cerebral hemorrhage) were identified as independent risk factors for acute cholecystitis after multivariate analysis. Acute cholecystitis was associated with greater operative difficulty and more postoperative morbidity than chronic cholecystitis. Therefore, an early cholecystectomy was recommended for the patients with risk factors for acute cholecystitis (5). Rationale • UDCA can dissolve gallstones, decrease cholesterol crystal formation, and reduce the bile saturation index. Comments • Patients must have a functioning gallbladder, and gallstones must be radiolucent in order to use UDCA. Gallstones optimally should be <5 mm in diameter. • Significant diarrhea will develop in 5% to 10% of patients taking UDCA. • The most definitive preventive strategy for cholecystitis is cholecystectomy. Because of suboptimal response rates and prolonged time needed for dissolution, medical therapy should be reserved for patients unable to have surgery. A study comprising 177 patients concluded that UDCA does not reduce biliary symptoms in highly symptomatic patients and that early cholecystectomy is warranted in patients with symptomatic gallstones (6). 1.2 Consider diclofenac in patients with biliary colic. Recommendations • Consider administering diclofenac, 75 mg, intramuscularly in a single injection. Evidence PIER is copyrighted ©2013 by the American College of Physicians. 190 N. Independence Mall West, Philadelphia, PA 19106, USA. Page 2 of 32 Acute Cholecystitis • A 2008 systematic review and meta-analysis that included seven randomized, controlled trials (n=349 patients) comparing the efficacy of NSAIDs with other analgesic agents in the treatment of biliary colic showed NSAIDs to be the analgesics of choice for biliary colic in limiting the progression of colic to acute cholecystitis (7). • A randomized, double-blind study of diclofenac showed satisfactory pain relief and decrease in progression to acute cholecystitis. Four of 27 patients treated with diclofenac developed acute cholecystitis compared with 11 of 26 placebo patients (P=0.04) (8). • A randomized, double-blind study of diclofenac vs. hyoscine for acute biliary colic showed faster and more effective pain relief in the diclofenac arm. A smaller percentage of patients in the diclofenac group (16.7%) progressed to acute cholecystitis compared with the hyoscine group (52.8%) (9). Rationale • Diclofenac provides pain relief in biliary colic and decreases the risk for acute cholecystitis. 1.3 Consider cholecystectomy for symptomatic gallstones. Recommendations • Consider laparoscopic cholecystectomy for patients with symptomatic gallstones. Evidence • A randomized, prospective study showed that in patients with biliary colic, 38% per year had recurrent biliary pain and 2% per year required cholecystectomy for significant biliary symptoms (10). • Based on simulation modeling, prophylactic cholecystectomy may decrease mortality more than conservative management in patients with symptomatic gallstones (11). • There are no randomized trials comparing cholecystectomy vs. no cholecystectomy in patients with silent gallstones. Further evaluation of observational studies, which measure such outcomes as obstructive jaundice, gallstone-associated pancreatitis, and/or gallbladder cancer for sufficient duration of follow-up, is necessary before randomized trials are designed to evaluate whether cholecystectomy or no cholecystectomy is better for asymptomatic gallstones (12). • The need for cholecystectomy was demonstrated in a study comparing outcomes in non- gangrenous (n=174) vs. gangrenous cholecystitis (n=106). Mortality was significantly higher in the latter group (0% vs. 4%; P=0.017). The risk factors associated with gangrenous cholecystitis included older age (69 years vs. 57 years; P=0.001) and diabetes (19%