Cholecystitis Treatment Guidelines

What is cholecystitis?

Cholecystitis is an inflammation of the gallbladder, a small organ located beneath the liver that stores bile, a fluid liver producer to digest fats. This condition is often caused by gallstones blocking the two common bile duct/s leading out of the gallbladder, leading to bile buildup and inflammation. However, cholecystitis can also occur from bile duct problems, tumors, or infections—even without gallstones.

Check out our resources for a comprehensive nursing care plan template for cholecystitis.

Types

There are several types of cholecystitis, including:

• Acute cholecystitis: This sudden inflammation, often resulting from gallstones blocking the cystic duct, includes a specific condition known as acute calculous cholecystitis—where the presence of gallstones directly causes the inflammation. Special considerations are required for patients with ACC, as they may experience more severe symptoms and complications.
• Chronic cholecystitis: This form results from repeated episodes of acute cholecystitis or long-term gallbladder inflammation. It can lead to a thickened gallbladder wall and decreased function over time.
• Acalculous cholecystitis: This type occurs without gallstones and is less common. It can happen in critically ill patients, often due to decreased blood flow or infection, and tends to be more severe.

Each type of cholecystitis has its treatment approach, ranging from medication and lifestyle changes to surgical removal of the gallbladder.

Diagnosing cholecystitis

Diagnosing cholecystitis involves a complete clinical examination to confirm inflammation of the gallbladder. "As no feature has sufficient diagnostic power to establish or exclude the diagnosis of ACC, it is recommended not to rely on a single clinical or laboratory finding." (Pisano, 2020)

Healthcare providers typically begin with a detailed discussion of your medical history, focusing on your symptoms. A physical exam will then assess for abdominal tenderness, particularly in the upper right quadrant where the gallbladder is located.

Blood tests are another crucial step. These tests check for elevated white blood cell counts, indicating infection or inflammation. However, the most definitive diagnostic tool lies in imaging studies.

Ultrasound is the preferred initial imaging technique due to its affordability, ease of access, and safety. It excels at visualizing gallstones, a hallmark of cholecystitis. Additionally, ultrasound can detect thickening of the gallbladder wall or fluid surrounding the organ, suggesting inflammation.

While ultrasound remains the first-line imaging test, other options like CT scans and magnetic resonance imaging (MRI) can provide even more detailed information. These advanced scans are beneficial in visualizing the common bile duct, which gallstones can sometimes obstruct. They can also detect any other abnormalities within the gallbladder itself.

In some situations, especially where surgery is not immediately possible, or the urgency needs further evaluation, gallbladder drainage might be considered. This procedure aims to manage severe symptoms or complications and can be a valuable tool for patient stabilization before definitive surgical intervention.

What is included in the Cholecystitis Treatment Guidelines?

The Cholecystitis Treatment Guidelines, recently updated by the World Society of Emergency Surgery and published in the World Journal of Emergency Surgery, provide a structured approach for managing acute calculous cholecystitis (ACC). These guidelines offer healthcare professionals comprehensive insights from initial management to definitive treatment and follow-up (Pisano et al., 2020).

Initial management

The initial management of cholecystitis involves symptom alleviation and stabilization of the patient. This phase includes instituting a period of fasting and bowel rest to reduce gallbladder stimulation. It is crucial to maintain intravenous hydration and correct any electrolyte imbalances. Pain management should primarily utilize non-opioid analgesics to avoid the risks associated with stronger medications. Intravenous antibiotics are recommended if an infection is suspected, which is often indicated by elevated white blood cell counts.

Surgical intervention

The definitive treatment for cholecystitis is surgical, with laparoscopic cholecystectomy being the primary recommendation. This minimally invasive surgery is preferred due to its numerous advantages such as shorter recovery times, less postoperative pain, and reduced infection risks. It is ideally performed within 72 hours of diagnosis to minimize complications. However, in cases where laparoscopic surgery is unsuitable due to severe complications or other contraindications, conversion to an open cholecystectomy may be necessary.

Managing complications

Complications from cholecystitis, such as gallbladder rupture or empyema, demand immediate and effective treatment. Managing these severe cases often involves gallbladder drainage to prevent sepsis, utilizing methods like percutaneous or endoscopic drainage depending on the patient's specific situation and available resources, including skilled endoscopists.

Follow-up care

After treatment, follow-up care is essential to ensure the patient's recovery and to monitor for potential complications or recurrence. Regular follow-up appointments are vital for assessing recovery and managing any complications that arise. Dietary recommendations focus on low-fat and moderate fiber intake to aid digestion and prevent future biliary issues.

Antibiotic treatment

The guidelines also specify the use of antibiotics in managing ACC. Routine postoperative antibiotics are not recommended for uncomplicated cases once the infection source is controlled. The antibiotic regimen should be tailored based on microbiological analysis results for complicated cases to ensure effective coverage, especially in patients at high risk for antimicrobial resistance.

Overall, these guidelines emphasize a tailored treatment approach, focusing on surgical and non-surgical options to optimize patient outcomes in managing cholecystitis.

How does the template work?

To effectively utilize the Cholecystitis Diagnostic Criteria Treatment Guidelines template, healthcare providers can follow these structured steps to ensure thorough diagnosis, treatment, and management of cholecystitis:

Step 1: Initiate diagnosis

Begin with a clinical evaluation to assess symptoms and patient history, which is crucial for distinguishing between acute and chronic cholecystitis. Follow up with the specific diagnostic tests outlined in the template, such as ultrasound, blood tests, and other imaging, to confirm the presence of gallbladder inflammation and stones.

Step 2: Develop a treatment plan

Use the template to outline tailored treatment strategies based on whether the cholecystitis is acute or chronic. This includes detailed plans for initial management such as pain relief and infection control. Decide on the appropriate intervention—surgical or non-surgical. The template guides providers in selecting laparoscopic cholecystectomy or alternative procedures like ERCP (Endoscopic Retrograde Cholangiopancreatography) or percutaneous cholecystostomy based on the patient’s condition and needs.

Step 3: Manage complications

Follow the template’s instructions for identifying and managing potential complications. This could involve additional interventions or adjustments in the treatment plan to address issues such as gallbladder rupture or severe infections.

Step 4: Optimize recovery and long-term management

After treatment, refer to the template for guidelines on post-operative care, including pain management, activity levels, and dietary recommendations to aid recovery and prevent recurrence. The template advises lifestyle adjustments and long-term dietary changes for chronic conditions to manage symptoms and improve quality of life.

Step 5: Document and adjust treatment

Document each step and adjustment in the patient’s medical records, as the template recommends keeping a detailed history of the treatment progression. Regularly review and adjust the treatment plan as necessary, based on the patient’s response to the treatment and any new developments in their condition.

Reference

Pisano, M., Allievi, N., Gurusamy, K., Borzellino, G., Cimbanassi, S., Boerna, D., Coccolini, F., Tufo, A., Di Martino, M., Leung, J., Sartelli, M., Ceresoli, M., Maier, R. V., Poiasina, E., De Angelis, N., Magnone, S., Fugazzola, P., Paolillo, C., Coimbra, R., & Di Saverio, S. (2020). 2020 World Society of Emergency Surgery updated guidelines for the diagnosis and treatment of acute calculus cholecystitis. World Journal of Emergency Surgery, 15(1). https://doi.org/10.1186/s13017-020-00336-x