CLINICAL GUIDELINE FOR MANAGEMENT OF ACUTE

CHOLECYSTITIS IN ADULTS

1. Aim/Purpose of this Guideline

This guideline is for the management of acute cholecystitis in adults. It has been
benchmarked against national guidelines to provide a detailed guidance of clinical
management of acute cholecystitis in line with best practice guidelines. This guideline
applies to all healthcare professionals involved in the treatment of acute cholecystitis.

2. The Guidance
The following pathway should be followed.

Clinical Guideline for Management of Acute Cholecystitis in Adults

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 ACUTE CHOLECYSTITIS TREATMENT PATHWAY
Diagnosis

A – Local inflammation
- Murphy’s sign
- RUQ mass / pain / tenderness

B – Systemic inflammation
- Fever
- Elevated CRP or WCC

C – Imaging
- Characteristic findings (pericholecystic fluid, wall thickening)
Suspected: One item in A + one item in B
Definite: One item in A + B + C



Detailed History & Examination
History of gallstones
Medication and drug intake
Recent intervention (e.g. ERCP / stent)
History of biliary stricture / malignancy
Co-morbidities (respiratory, cardiac, diabetes, high BMI)



Investigations
a) FBC, U+Es, LFTs, amylase, CRP
b) Blood cultures
c) Upper abdominal ultrasound



Immediate Management

A Ensure patent airway
B Oxygen – target 94-98% saturation (88-92% if COPD)

C Intravenous fluids

- Hartmanns solution
- Administer 30ml/kg for hypotension or lactate ≥4mmol/l
- 5-10mls/kg/h first 24 hours until goals met
- Goals to meet:-
- Heart rate <120/min
- Mean arterial pressure = 65-85mmHg
- Urine output = 0.5-1ml/kg/h

Urinary catheter – if evidence of oliguria or anuria
D/E Antibiotics

Amoxicillin IV 500mg 8 hourly + Gentamicin

Add metronidazole IV 500mg 8 hourly if anaerobes suspected

If penicillin allergy: Vancomycin + Gentamicin +/- metronidazole

Clinical Guideline for Management of Acute Cholecystitis in Adults
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Is Systemic Inflammatory Response Syndrome (SIRS) Present?

Any 2 of the following:
- Respiratory rate >20
- Heart rate >90
- WCC <4 or >12
- Temp <36°c or >38°c

Presence of SIRS on admission is a predictor of SEVERE cholecystitis and requires senior
surgical review.



Severity Assessment (TG13 classification) - Assess at admission, 24 hours and 48 hours

Severe: At least one organ dysfunction* URGENT (<24 h) cholecystectomy or

radiological drainage

Moderate: Any one of the following: - EARLY (<48h) cholecystectomy or
- WCC >18 radiological drainage
- Palpable RUQ mass
- Duration >72 hours
- Marked local inflammation
(gangrenous, abscess, peritonitis, emphysematous)

Mild: Do not meet above criteria Cholecystectomy within 7 days or as OP



Urgent senior surgical & ITU outreach review if any of below:-

Clinical signs Bloods
A Airway not maintained pH <7.1 or >7.7

B: Resp. rate >35/min Sodium <110 or >170mmol/l
paO2 <6.7kPa Potassium <2.0 or >7.0mmol/l

C: HR<40 or >150/min Calcium >3.75mmol/l
Systolic blood pressure <80mmHg Glucose >44.4mmol/l
MAP <60mmHg
Diastolic blood pressure >120mmHg
Anuria Severity grading

D: Coma (GCS <8) Severe cholecystitis



Consideration of HDU involvement where:-

- Persistent SIRS >48h *Organ dysfunction definitions:-
- Elderly (aged >75yrs)
Cardiovascular - Hypotension requiring inotropes
- Obese (BMI>35) Respiratory - Type 1 or 2 respiratory failure
- Moderately severe cholecystitis Renal - Oliguria or creatinine >177umol/L
Hepatic - INR >1.5
Haematological - Platelets <100 (10*9/L)
Neuro - Impaired consciousness
Clinical Guideline for Management of Acute Cholecystitis in Adults
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3. SPECIFIC GUIDELINES REGARDING MANAGEMENT
3.1. Ownership
o All patients with a suspected or definite diagnosis of acute cholecystitis should be
admitted under the acute general surgery team.
o Current evidence suggests that laparoscopic cholecystectomy is the most clinically
and cost effective treatment for acute cholecystitis and should ideally be performed
within the first 72 hours after the onset of symptoms. Surgery is still considered safe
up to 7 days following onset of symptoms.

3.2. Imaging
o Gold standard first line investigation is USS abdomen
o CT indications:-
 Diagnostic uncertainty
 Assess for complications of acute cholecystitis (e.g. liver abscess / perforation)
 Where patient fails to improve despite initial treatment
o MRCP indications:-
 Where common bile duct stone suspected
 Suspected Mirizzi
o On table cholangiogram indications:-
 History of abnormal LFTs or dilated CBD
 Assess anatomy of biliary tree

3.3. Cholecystectomy
o SEVERE: Patient should be offered urgent cholecystectomy where deemed surgically
fit otherwise urgent radiological biliary drainage with percutaneous cholecystostomy.
o MODERATE: As above
o MILD: Patients considered fit for surgery should be offered cholecystectomy during
their index admission. This should be performed within 72 hours, however surgery is
still considered safe up to 7 days from onset of symptoms. Where this is not
achievable patients should have a date for subsequent surgery identified prior to
discharge or outpatient review as appropriate.

3.4. Percutaneous cholecystostomy tube

o Patients considered for this procedure require discussion with the Consultant
interventional radiologist.
o Contrast cholecystostogram is optional. Removal should be routinely at 6 weeks.

3.5. Acalculous cholecystitis

o This can account for around 10% of cases of acute cholecystitis. Initial management
should follow the pathway above.
3.6. References
o Kiriyama S, Takada T, Strasberg SM et al. Updated Tokyo guidelines for acute
cholangitis and acute cholecystitis. J Hepatobiliarypancreatic sciences. 2013;
20(1):24-34.
o AUGIS. Pathway for the management of acute gallstone diseases. AUGIS 2015.
o NICE. Gallstone disease: diagnosis and initial management. 2014 (CG188)
o Gurusamy K, Davidson C, Gluud C, Davidson BR. Early versus delayed laparoscopic
cholecystectomy for people with acute cholecystitis. Cochrane Database of Systematic
Reviews 2013, Issue 6. Art. No.: CD005440. DOI: 10.1002/14651858.CD005440.pub3

Clinical Guideline for Management of Acute Cholecystitis in Adults

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4. Monitoring compliance and effectiveness
Element to be All
monitored
Lead Mr Michael Clarke

Tool Patient documentation and Rolling audit

Frequency Adult acute cholecystitis patients who are reviewed by specialist teams.
Audit 6 monthly
Reporting Involved specialties governance committees. Repeated non-compliance
arrangements to be reported via Datix
Acting on Hospital Working Group
recommendations Michael Clarke (Consultant upper GI surgeon) - Chair
and Lead(s) Mohamed Abdelrahman (ST3 General Surgery)
Ian Finlay (Consultant upper GI surgeon)
Hyder Hussaini (Consultant gastroenterologist)
Bill Stableforth (Consultant gastroenterologist)
Madeline Strugnell (Consultant radiologist)
Dushyant Shetty (Consultant radiologist)
John Hancock (Consultant interventional radiologist)
Mike Spivey (Consultant in Intensive Care)
Change in practice Required changes to practice will be identified and actioned within 6
and lessons to be months. A lead member of the team will be identified to take each change
shared forward where appropriate. Lessons learned or changes to practice will
be shared with all stakeholders.

5. Equality and Diversity

5.1. This document complies with the Royal Cornwall Hospitals NHS Trust service
Equality and Diversity statement which can be found in the 'Equality, Diversity & Human
Rights Policy' or the Equality and Diversity website.

5.2. Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

Clinical Guideline for Management of Acute Cholecystitis in Adults

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Appendix 1. Governance Information
Clinical Guideline for Management of acute
Document Title
cholecystitis in Adults.
Date Issued/Approved: 23/02/2016
Date Valid From: 23/02/2016
Date Valid To: 23/02/2019
Mr Michael Clarke (Consultant Upper GI and
Directorate / Department responsible
Bariatric Surgeon)
(author/owner):
Mr Mohamed Abdelrahman (Upper GI Spr)
Contact details: Mr Michael Clarke (01872 252373)
This guideline is for the management of acute
cholecystits in adults. This guideline applies to all
Brief summary of contents
healthcare professionals involved in the treatment
of acute cholecystits.
Suggested Keywords: cholecystitis
RCHT PCH CFT KCCG
Target Audience

Executive Director responsible for
Medical Director
Policy:
Date revised: None
This document replaces (exact title of
Nil
previous version):
Hospital working group
Michael Clarke (Consultant upper GI surgeon) - Chair
Ian Finlay (Consultant upper GI surgeon)
Hyder Hussaini (Consultant gastroenterologist)
Approval route (names of Bill Stableforth (Consultant gastroenterologist)
committees)/consultation: Madeline Strugnell (Consultant radiologist)
Dushyant Shetty (Consultant radiologist)
John Hancock (Consultant interventional radiologist)
Mike Spivey (Consultant in Intensive Care)
Divisional Governance Committee
Divisional Manager confirming Divisional Director
approval processes Duncan Bliss
Name and Post Title of additional
Not required
signatories
Name and Signature of
Divisional/Directorate Governance {Original Copy Signed}
Lead confirming approval by
specialty and divisional management Name:
meetings
Signature of Executive Director
{Original Copy Signed}
giving approval
Publication Location (refer to Policy
on Policies – Approvals and Internet & Intranet  Intranet Only
Ratification):
Document Library Folder/Sub Folder Clinical / General Surgery
Links to key external standards None
Related Documents: Nil
Training Need Identified? No
Clinical Guideline for Management of Acute Cholecystitis in Adults
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Version Control Table

Version Changes Made by

Date Summary of Changes
No (Name and Job Title)

Michael Clarke –
01 09 15 V1.0 Draft for consultation Consultant Upper GI
and Bariatric Surgeon

Michael Clarke –
23 Feb 16 V2.0 Approved for implementation Consultant Upper GI
and Bariatric Surgeon

All or part of this document can be released under the Freedom of Information Act
2000

This document is to be retained for 10 years from the date of expiry.

This document is only valid on the day of printing

Controlled Document
This document has been created following the Royal Cornwall Hospitals NHS Trust Policy
on Document Production. It should not be altered in any way without the express
permission of the author or their Line Manager.

Clinical Guideline for Management of Acute Cholecystitis in Adults

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Appendix 2. Initial Equality Impact Assessment Form
Name of Service, strategy, policy or project to be assessed (hereafter referred to as policy) :
Clinical Management of Acute Cholecystitis in Adults
Directorate and service area: General Is this a new or existing Policy? New
Surgery
Name of individual completing Telephone: 01872252373
assessment: Mr Michael Clarke
1. Policy Aim* To provide detailed guidance on the clinical management of acute
Who is the strategy / cholecystitis in line with best practice guidelines.
policy / proposal /
service function
aimed at?
2. Policy Objectives*  To provide a consistent approach to the management of acute
cholecystitis at RCHT sites.
 To maintain patient safety and improve outcomes for patients
experiencing acute cholecystitis whilst inpatients at RCHT sites
3. Policy – intended  Consistent management of acute cholecystitis at RCHT sites.
Outcomes*  Prompt and safe management of acute cholecystitis and follow up
care.
4. *How will you  Audit
measure the  Datix Reporting
outcome?  Review of nursing/ medical documentation as required
5. Who is intended to All patients who experience acute cholecystitis in hospital at RCHT
benefit from the sites.
policy?
6a) Is consultation Yes
required with the
workforce, equality
groups, local interest
groups etc. around
this policy?

b) If yes, have these Yes

*groups been
consulted?

C). Please list any General surgery team (Audit meeting). Consultants (Radiology,
groups who have Gastroenterology, Microbiology, Intensive care)
been consulted about
this procedure.

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7. The Impact
Please complete the following table.
Are there concerns that the policy could have differential impact on:
Equality Strands: Yes No Rationale for Assessment / Existing Evidence
Age x
Sex (male, female, trans- x
gender / gender
reassignment)
Race / Ethnic x
communities /groups
Disability - x
Learning disability, physical
disability, sensory impairment
and mental health problems
Religion / x
other beliefs
Marriage and civil x
partnership
Pregnancy and maternity x
Sexual Orientation, x
Bisexual, Gay, heterosexual,
Lesbian
You will need to continue to a full Equality Impact Assessment if the following have been
highlighted:
 You have ticked “Yes” in any column above and
 No consultation or evidence of there being consultation- this excludes any policies
which have been identified as not requiring consultation. or
 Major service redesign or development
8. Please indicate if a full equality analysis is recommended. No

9. If you are not recommending a Full Impact assessment please explain why.

Signature of policy developer / lead manager / director Date of completion and submission
Michael Clarke, Consultant Upper GI and Bariatric 23rd February 2016
Surgeon
Names and signatures of 1.
members carrying out the 2.
Screening Assessment

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead,
c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa,
Truro, Cornwall, TR1 3HD

A summary of the results will be published on the Trust’s web site.

Signed _______________

Date ________________

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