Only Internationally recognized guidelines regarding acute cholecystitis

1. TG13: UPDATEDTOKYO GUIDELINES FOR
ACUTE CHOLECYSTITIS
Jibran Mohsin
Resident, Surgical Unit I
SIMS/Services Hospital, Lahore

2. Background
■ BeforeTG07, there were no practical guidelines through out the world primarily
targeting acute cholecystitis
■ TG07 was updated after
– total 35 meetings ofTokyo Guidelines RevisionCommittee for revision of
TGO7(TGRC)
– email exchanges with co authors abroad e.g. USA, Netherlands,UK, Germany, New
Zealand, India, Korea,China, Greece, Hong Kong, Italy, Philippines,Taiwan,
Singapore, Argentina, Australia and Malaysia
– 3 International Meetings for the Clinical Assessment and Revision ofTokyo
Guidelines

3. OUTLINE
■ Terminology, Etiology and Epidemiology
■ Diagnostic Criteria
■ Severity assessment criteria/grading
■ Differential Diagnosis
■ Management
– Antimicrobial therapy
– Gallbladder drainage
– Surgical management
■ Summary
– Management bundle
– AcuteCholecystitis BundleChecklist

4. Terminology, Etiology and Epidemiology
■ Definition
– Acute inflammatory disease of gallbladder, often attributable to gallstones, but
many factors such as ischemia, motility disorders, direct chemical injury, infections
by microorganism, protozoon and parasites, collagen disease, and allergic reaction
are also involved

5. Terminology, Etiology and Epidemiology
■ Pathophysiology
– Gallstones are the cause of acute cholecystitis in majority of cases
– Involves physical obstruction at neck or in cystic duct by gallstone
– Leading to increased pressure in GB
– Determined by degree of obstruction and duration of obstruction
■ i.e. partial and short duration  biliary colic
■ Complete and long duration  Acute cholecystitis
■ If early treatment not given  severe disease and risk of complications

6. Terminology, Etiology and Epidemiology
■ PathologicalClassification
STAGE FINDINGS
EdematousCholecystitis 1st Stage 2-4 days • Interstitial fluid with dilated capillaries and lymphatics
• Edematous wall (sub serosal layer) of GB
• Intact GB tissue
Necrotizing Cholecystitis 2nd Stage 3-5 days • Edematous changes with areas of hemorrhage and scattered necrosis
(superficial, not full thickness)
• Vascular thrombosis and occlusion
SuppurativeCholecystitis 3rd Stage 7-10 days • WBC infiltration with areas of necrosis and suppuration
• Active repairing process of inflammation
• Contracted and thick wall due to fibrosis
• Intramural (not entire thickness) and pericholecystic abscesses
Chronic Cholecystitis • Repeated attacks of mild
cholecystitis
• Mucosal atrophy and fibrosis of GB wall
• Chronic irritation by large gallstones
• Acute on chronic cholecystitis • Neutrophil invasion + lymphocyte/plasma cell infiltration

7. Terminology, Etiology and Epidemiology
■ Special forms of acute cholecystitis
Acalculous Cholecystitis Acute cholecystitis wtihout cholecystoithiasis
Xanthogranulomatous cholecystits • Cholecystitis with xanthogranulomatous thickening of GB wall and raised GB pressure due
to stones with rupture of Rokitansky-Aschoff sinuses.
• Leakage and entry of bile into GB wall, ingested by histiocytes to form granulomas
containing foamy histiocytes
Emphysematous Cholecystitis • Air inGB wall due to gas-forming anaerobes including Clostridium perfringens
• Often seen in diabetes and likely to progress to sepsis and gangrenous cholecystitis
Torsion of GB • INHERITED FACTORS: floating GB
• ACQURIED FACTORS: splanchoptosis, senile humpback, scoliosis, weight loss
• PHYSICAL FACTORS: sudden change in intraperitoneal pressure, sudden change of body
position, pendulum-like movement in anteflexion position, hyperperistalsis of organs near
GB, defecation, and blow to abdomen

8. Terminology, Etiology and Epidemiology
■ Advanced forms of and the type of complications of acute cholecystitis
Perforation of gallbladder • Due to acute cholecystitis, injury or tumors
• Most frequently due to ischemia and necrosis of GB wall
Biliary Peritonitis • Due to cholecystitis-inducedGB perforation, trauma, and detached catheter during biliary
drainage and incomplete suture after biliary operation
Pericholecystitic abscess • Perforation of GB covered by surrounding tissue along with formation of abscesses around GB
Biliary fistula • Between GB and duodenum following an episode of acute cholecystitis
• Due to large stone eroding through GB wall into duodenum
• Can also cause gallstone ileus (mechanical obstruction by stone at ileocecal valve)

9. Terminology, Etiology and Epidemiology
■ Incidence
– Around 10 % of general population have gallstones
– 20-40 % of asymptomatic gallstone have risk for developing some type of S/S. (1-3
% annually)
– 1-2 % asymptomatic and 1-3 % mild symptomatic gallstones annually present with
severe symptoms or complications (acute cholecystitis/cholangitis/ pancreatitis and
severe jaundice)

10. Terminology, Etiology and Epidemiology
■ Incidence
– Acute cholecystitis – most frequent complication of cholelithiasis (3.8 - 12 %)
– 6.0 % cases are of severe (accompanying organ dysfunction-Grade III) acute
cholecystitis
– 0.2 – 1.0 % cases of ERCP develop acute cholystitis

11. Terminology, Etiology and Epidemiology
■ Etiology
– 90-95 % gallstones
– 3.7 – 14 % acalculous cholecysytitis
■ Mechanism
– Gallstone  Cystic duct obstruction  bile stasis  activation of inflammatory
mediators and mucosal injuries

12. Terminology, Etiology and Epidemiology
■ Risk Factors
– “4Fs” ( forties, female, fat, fair) and “5Fs” ( 4Fs + fecund or fertile) associated with
lithogenesis in GB but no established association with acute cholecystitis except obesity
– Drugs: Hormone replacement therapy (2X), thiazides?, Hepatic artery chemotherapy,
statins (protective)
– AIDS (AIDS cholangiopathy and acute acalculous cholecystitis)
– Parenteral Nutrition, thermal burn, infection, surgery, trauma, long term ICU stay

13. Terminology, Etiology and Epidemiology
■ Prognosis
Mortality rate
Grade I 0.6 %
Grade II 0 %
Grade III 21.4 %
overall 1.7 %

14. Terminology, Etiology and Epidemiology

15. Diagnostic Criteria
■ Murphy’s (1903) sign shows high specificity( 79 – 96 %), however the sensitivity has
been reported low ( 50-65 %), thus not applicable in making a diagnosis of acute
cholecystitis due to low sensitivity
TG13 Diagnostic criteria for acute cholecystitis
A. Local signs of inflammation etc. 1. Murphy’s sign
2. RUQ mass/pain/tenderness
B. Systemic signs of inflammation etc. 1. Fever
2. Elevated CRP
3. Elevated WBC count
C. Imaging findings Characteristic of acute cholecystitis
SUSPECTED DIAGNOSIS: one item in A + one item in B
DEFINITE DIAGNOSIS: one item in A + one item in B + C
Sensitivity (91 %)
Specificity (97%)
IMAGING:
USG
CT
Tc-HIDA scans

16. Diagnostic Criteria
■ Most typical clinical sign of acute cholecystitis is abdominal pain ( RHC or epigastric) -72-93 %
■ Followed in frequency by nausea and vomiting
■ Fever >38OC only in 30 % cases
■ Muscular defense (guarding) in 50 % cases
■ Palpable tumors, rebound tenderness, stiffness (rigidity) are rare

17. Diagnostic Criteria

18. Diagnostic Criteria
■ No specific blood tests for making a diagnosis of acute cholecystitis
– General inflammatory findings (> 10,000 mm3/dLTLC, > 3 mg/dLCPR level)
– Mild increase of serum enzymes in hepatobiliary system
– Raised bilirubin (up to 4 mg/dL) even in absence of complications

19. Diagnostic Criteria
■ Ultrasonography should be performed at the initial consultation for all cases for which
acute cholecystitis is suspected (satisfactory diagnostic capability even if done by ER
physicians)
■ Ultrasonography shows 50-88 % sensitivity and 80-88 % specificity
■ Diagnostic if all of following are present
– Thickening of GB wall (5mm or more)
– Pericholecystic fluid
– Direct tenderness when probe is pushed against GB (ultrasonographic Murphy’s sign
– superior to ordinary Murphy’s sign in that it is possible to press GB accurately i.e 90
% sensitivity and specificity)

20. Diagnostic Criteria
■ Others
– GB enlargement, GB stones(13 % cases), debris echo and gas imaging
– sonolucent(hypoechoic) layer, referred to as a low-echo zone (8 % sensitivity, 71 %
specificity)
– Low-echoic area with an irregular multiple structure (62 % sensitivity, 100 %
specificity)

21. Diagnostic Criteria
■ Findings on contrast enhanced CT characteristic of acute cholecystitis
– GB distension (41 %)
– Pericholecystic fat stranding/density (52 %)
– GB wall thickening (59 %)
– Subserosal edema (31 %)
– Mucosal enhancement
– Transient focal enhancement of liver adjacent to gallbladder due to increased venous flow in cholecystic
vein draining directly into liver parenchyma
( during arterial phase of dynamic CT, disappears during portal and equilibrium phase)
– Pericholecystic fluid collection (31 %)
– Pericholecystic abscess
– Gas collection within GB
– High- attenuation GB bile (24 %)

22. Diagnostic Criteria
■ Tc-HIDA scan
– GB normally visualized within 30 min if cystic duct is patent i.e. no cholecystitis
– Failure of GB to fill within 60 min after administration of tracer  obstructed cystic duct
– 80-90 % sensitivity for acute cholecystitis
– False positive largely explained by cystic duct obstruction induced by chronic inflammation and some
cases normal GB don’t fill due to SOD
– “Rim sign” = blush of increased pericholecystic radioactivity (30 % cases)
– Significantly higher specificity and accuracy than US

23. Diagnostic Criteria
US versusTc-HIDA scan
■ Gold standard isTc-HIDA scan
■ BUT initial investigation of choice is US
– Immediate availability
– Easy access
– Lack of interference by elevated serum bilirubin levels (cholestasis interferes with
biliary excretion of agents used for scintigraphy)
– Absence of ionizing radiation
– Information regarding presence of stone

24. Severity assessment criteria/grading

25. Differential Diagnosis
■ Gastric and Duodenal ulcer
■ Hepatitis
■ Pancreatitis
■ GB cancer
■ Hepatic abscess
■ Fitz-Hugh-Curtis syndrome
■ Right lower lobar pneumonia
■ Angina pectoris/MI
■ UTI

26. Flowchart for management
1st LineT/M
1st LineT/M

27. Management
■ Initial medical treatment while considering for surgery and ER drainage
– Nill By Mouth
– IV hydration and electrolytes correction
– Antimicrobial
– Analgesic
– Respiratory and hemodynamic monitoring
■ Appropriate organ support in severe acute cholecystitis
– Artificial respiration, intubation and vasopressors
– along with ER drainage/cholecystectomy

28. Management
■ Analgesics should be initiated in early stage as it doesn’t affect positive rate of
sonographic Murphy’s sign
■ NSAID (diclofenac 75 mg IM) administration is effective for impacted stones attack for
PREVENTING acute cholecystitis
■ NSAID also effective for improvement of GB function in chronic cholecystitis
■ NOT effective to improve the course of cholecystitis after its acute onset

29. Antimicrobial therapy
■ Primary Goal
– To limit both systemic septic response and local inflammation
– To prevent SSI (superficial, deep, organ space)
– To prevent intrahepatic abscess formation
■ Early and non-severe cases  Prophylactic
■ Others with SIRS  therapeutic

30. Antimicrobial therapy

31. Antimicrobial therapy
■ Bile cultures should be obtained at the beginning of any procedure performed. GB bile
should be sent for culture in all cases of acute cholecystitis expecting those with grade
I severity
■ TG13 suggest cultures of bile and tissue when perforation, emphysematous changes,
or necrosis of GB are noted during cholecystectomy
■ Blood cultures are not routinely recommended for grade I community-acquired acute
cholecystitis

32. Antimicrobial therapy
■ Factors influencing the selection of antimicrobial agents for acute cholecystitis
– Targeted organisms
– Pharmacokinetics
– Pharmacodynamics
– Local Antibiogram (local epidemiology and susceptibility data)
– H/O antimicrobial usage (< 6 months, increased risk of resistance)
– Renal and hepatic function (Dosage adjustment)
– H/O of allergies and other adverse events

33. Antimicrobial therapy
■ Initiated as soon as diagnosis of acute cholecystitis is suspected
– For case in septic shock, within 1 h of recognition
– For other cases, as long as 4 h may be spent obtaining definitive diagnostic studies
prior to beginning antimicrobial therapy
– Should definitely be started before any procedure (endoscopic or operative)
■ Anaerobic therapy is appropriate if biliary-enteric anastomosis is present

34. Antimicrobial therapy
Velosef (Cephradine)
Oxidil (Ceftriaxone)
Zinacef (Cefuroxime)
Tanzo/Tazocin (Piperacillin/tazobactam)
Teinam (Imipenem/cilstatin)
Meronem (Meropenem)

35. Antimicrobial therapy
■ Historically, biliary penetration of agents has been considered in selection of
antimicrobial agents
■ However, there is considerable lab and clinical evidence that as obstruction occurs,
secretion of antimicrobial agents into bile stops. (need RCT to determine clinical
relevance and significance of biliary penetration in treating acute cholecystitis)

36. Antimicrobial therapy

37. Antimicrobial therapy
Patients who can tolerate oral feeding may be treated with oral therapy.

38. Antimicrobial therapy
Use of Antibiotic irrigation
■ Irrigation of surgical fields with antimicrobial agents
■ Clearly effective in reduction of wound infection
■ May be effective as effective as use of systemic antimicrobial agents
■ Combined use of systemic and topical antimicrobial agents may have additive effects
(especially if different agents are used)

39. GB Drainage
GBDrainage
PercutaneousTrans hepatic GB
Drainage (PTGBD)
Aspiration (PTGBA)
Endoscopic
transpapillary
Naso(-biliary) GB drainage (ENGBD)
GB stenting (EGBS)
Endoscopic Ultrasound (EUS)-guided
Naso(-biliary) GB drainage
GB stenting

40. GB Drainage
■ Percutaneous transhepaticGB drainage (PTGBD)
– Recommended essentialStandard GB drainage method for surgically unfit patients
with acute cholecystitis
– Safe alternative to one-shot definitive treatment in form of early cholecystectomy in
surgically high risk populations e.g. mortality rate in elderly or critically ill patients
up to 19 %
– Low complication rate 0-13 % with procedure related mortality 0.36 %

41. GB Drainage
■ Grade II  only when patient does not respond to conservative treatment
■ Grade III  recommended with intensive care
■ PREDICTOR FOR FAILUREOF CONSERVATIVETREATMENT:
AT 24-h and 48-h follow-up
• WBC >15000 cell/µl
• Elevated temperature
• Age > 70 years
AT ADMISSION
• Age > 70 years
• Diabetes
• Tachycardia
• Distended GB

42. GB Drainage
6- to 10-Fr pigtail
catheter
Under fluoroscopy
(Seldinger technique)

43. GB Drainage

44. GB Drainage
INDICATION:
end-stage liver disease (in whom
percutaneous approach is difficult to
perform)

45. GB Drainage

46. GB Drainage

47. GB Drainage

48. GB Drainage

49. Surgical Management
Grade I (mild) EARLY laparoscopicCholecystectomy
Grade II (moderate) MOST CASES EARLY laparoscopic or open cholecystectomy
(within 72 hr after onset of acute cholecystitis) in
experienced centers
“difficult gallbladder” ( severe local
inflammation i.e. >72 h from onset, WBC
count >18,000 and palpable tender mass in
RUQ)
continues medical treatment or drainage (PTGBD
or surgical cholecystostomy) preferable
DELAYED cholecystectomy
Serious local complications(biliary
peritonitis, pericholecystic abscess, liver
abscess, GB torsion or emphysematous/
gangrenous/ purulent cholecystitis
EMERGENCY open or laparoscopic depending on
experience (along with general supportive care)
Grade III (severe) DELAYED cholecystectomy (2-3 months later after
improvement of patient’s general condition) when
indicated

50. Surgical Management
OPTIMAL APPROACH
■ Until 1st half of 1990’s --.Open cholecystectomy was the standard technique of acute
cholecystitis
■ Open cholecystectomy with mini-incision is able to produce as good results as those
obtained by laparoscopic procedure although superiority of laparoscopic procedure is
now well established
■ TG13 recommends laparoscopic cholecystectomy over open cholecystectomy
■ However, the 1st priority is ALWAYS patient safety

51. Surgical Management
OPTIMALTIMING
■ Preferable to perform cholecystectomy soon after admission, particularly when less
than 72 hours have been passed since the onset of symptoms
■ Definition of early surgery  within 72-96 h from onset of symptoms (NOT time of
diagnosis or admission)
■ Definition of elective (DELAYED) surgery  6 weeks or more after onset

52. Surgical Management
OPTIMALTIME FOR CONVERSION FROM LAPAROSCOPICTO OPEN
CHOLECYSTECTOMY
■ Surgeons should NEVER hesitate to convert to open surgery to prevent injuries when
they experience difficulties in performing laparoscopic cholecystectomy i.e. low
threshold

53. Surgical Management
■ Optimal time for cholecystectomy following PTGBD
– Often performed after several days/2 weeks
– BUT remains controversial due to lack of any strong evidence(no RCT)
■ Optimal time for cholecystectomy following endoscopic stone extraction of bile duct
in patients with cholecysto-choledocholithiasis in acute cholecystitis
– No definitive conclusions could be made due to insufficient evidence

54. Management bundle
■ Bundle = collection of mandatory items or procedures to be performed in clinical
practice OR
■ Group of therapies for a disease that, when implemented together, may result in
better outcomes than if implemented individually

55. Management bundle

56. Management bundle

57. Management bundle

58. Acute Cholecystitis Bundle Checklist

59. Available at surgicalpresentations