Follow-up
Further Inpatient Care
- Objectives during inpatient stay include the following:
- Correction of fluid and electrolyte abnormalities
- Antibiotics for complicating infections
- Performing imaging studies as appropriate (eg, ultrasound, HBS)
- Cholecystectomy once the patient is stable or percutaneous transhepatic cholecystostomy drainage in unstable high-risk surgical patients
Further Outpatient Care
- In cases of uncomplicated cholecystitis, outpatient treatment may be appropriate. If a patient can be treated as an outpatient, discharge with antibiotics, appropriate analgesics, and definitive follow-up care. Criteria for outpatient treatment include the following:
- Afebrile with stable vital signs
- No evidence of obstruction by laboratory values
- No evidence of common bile duct obstruction on ultrasound
- No underlying medical problems, advanced age, pregnancy, or immunocompromised condition
- Adequate analgesia
- Reliable patient with transportation and easy access to a medical facility
- Prompt follow-up care
Inpatient & Outpatient Medications
- For outpatient treatment of uncomplicated cholecystitis, the following medicines may be appropriate:
- Prophylactic antibiotic coverage with Levaquin (500 mg PO qd) and Flagyl (500 mg PO bid), which should provide coverage against the most common organisms
- Antiemetics, such as oral/rectal Phenergan or Compazine, to control nausea and to prevent fluid and electrolyte disorders
- Analgesics, such as oral Percocet or Vicodin
Transfer
- Consider patient transfer if the following conditions apply:
- Appropriate diagnostic resources are not available.
- Higher level of care is required.
- Surgeons and/or specialists are unavailable.
Deterrence/Prevention
- Prevention of cholecystitis requires cholecystectomy.
- In patients who are unstable, percutaneous transhepatic cholecystostomy drainage may be appropriate.
- Some studies have shown that daily CCK administration may help prevent acalculous cholecystitis in patients at risk.
Complications
- Bacterial proliferation within the obstructed gallbladder results in empyema of the organ. Patients with empyema may have a toxic reaction and may have more marked fever and leukocytosis. The presence of empyema frequently requires conversion from laparoscopic to open cholecystectomy.
- In rare instances, a large gallstone may erode through the gallbladder wall into an adjacent viscus, usually the duodenum. Subsequently, the stone may become impacted in the terminal ileum or in the duodenal bulb and/or pylorus, causing a gallstone ileus.
- Emphysematous cholecystitis occurs in approximately 1% of cases and is noted by the presence of gas in the gallbladder wall from the invasion of gas-producing organisms, such as E coli, Clostridia perfringens, and Klebsiella species. This complication is more common in patients with diabetes, has a male predominance, and is acalculous in 28% of cases. Because of a high incidence of gangrene and perforation, emergency cholecystectomy is recommended.
- Sepsis
- Pancreatitis
- Perforation occurs in up to 15% of patients.
Prognosis
- For uncomplicated cholecystitis, the prognosis is excellent, with a very low mortality rate.
- In patients who are critically ill with cholecystitis, the mortality rate approaches 50-60%, especially in the setting of gangrene or empyema.
- Once complications such as perforation/gangrene develop, the prognosis becomes less favorable. In patients who are critically ill with acalculous cholecystitis and perforation or gangrene, the mortality rate can be as high as 50-60%.
Patient Education
- Patients diagnosed with cholecystitis must be educated regarding causes of their disease, complications if left untreated, and medical/surgical options to treat cholecystitis.
- For excellent patient education resources, visit eMedicine's Liver, Gallbladder, and Pancreas Center. Also, see eMedicine's patient education articles Gallstones and Pancreatitis.
Miscellaneous
Medicolegal Pitfalls
- Delays in making the diagnosis of acute cholecystitis result in a higher incidence of morbidity and mortality. This is especially true for ICU patients who develop acalculous cholecystitis. The diagnosis should be considered and investigated promptly in order to prevent poor outcomes.
Special Concerns
- Pregnancy
- RUQ pain in pregnancy can be related to a number of different diagnoses, including preeclampsia, appendicitis, and cholelithiasis.
- These patients must have a thorough examination because complications can arise quickly and can be life threatening to both the mother and the unborn child.
- Although laparoscopic cholecystectomy is considered safest during the second trimester, it has been performed successfully during all trimesters.
- Elderly patients (especially patients with diabetes) may present with vague symptoms and without many key historical and physical findings. Elderly patients may also progress to complicated cholecystitis rapidly and without warning.
- The pediatric population may also present without many of the classic findings. Children who are at higher risk for developing cholecystitis include patients with sickle cell disease, seriously ill children, those on prolonged TPN, those with hemolytic conditions, and those with congenital and biliary anomalies.
- Patients who are immunocompromised are at increased risk of developing cholecystitis from a number of different infectious sources.
More on Cholecystitis |
| Overview: Cholecystitis |
| Differential Diagnoses & Workup: Cholecystitis |
| Treatment & Medication: Cholecystitis |
 Follow-up: Cholecystitis |
| Multimedia: Cholecystitis |
| References |
| « Previous Page | Next Page » |
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Further Reading
Keywords
cholecystitis, cholelithiasis, gallstones, gallbladder stones, gallbladder inflammation, cystic duct obstruction, cystic duct stones, acute cholecystitis, chronic cholecystitis, emphysematous cholecystitis, acalculous cholecystitis, calculous cholecystitis, stones in the cystic duct, obstruction of the cystic duct, biliary pain, acalculous biliary colic, calculous biliary colic, biliary stasis, cholecystectomy, sepsis, long-term total parenteral nutrition, long-term TPN, prolonged fasting, sickle cell disease, Salmonella infections, diabetes mellitus, cytomegalovirus, cryptosporidiosis, microsporidiosis infections, obesity, jaundice, major surgery, severe trauma, severe burns, myocardial infarction
