01Approach to the Critical Patient/attcp44

Immediate priorities

›Life-threatening presentations

›Septic cholecystitis (Tokyo Grade III)

›Hypotension SBP < 90 mmHg

›Altered mental status

›Respiratory failure

›Renal dysfunction creatinine > 176 umol/l

›Gallbladder perforation

›Peritonitis with guarding and rigidity

›Pneumoperitoneum on imaging

›Emphysematous cholecystitis

›Gas in gallbladder wall on imaging

›Diabetic male with rapid deterioration

›Resuscitation priorities

›IV access and fluid resuscitation

›Two large-bore peripheral IVs

›30 ml/kg crystalloid bolus for septic shock

›Broad spectrum antibiotics within 1 hour for Grade III

›Class I recommendation for septic cholecystitis

›Do not delay for imaging if clinical sepsis

›NPO status for surgical candidacy

›No oral intake pending surgical evaluation

›IV analgesia titration

Monitoring and targets

›Hemodynamic monitoring

›MAP target > 65 mmHg

›Norepinephrine if unresponsive to fluids

›Arterial line for severe sepsis

02History/hx43

Presentation pattern

›Classic symptom complex

›Right upper quadrant pain

›Onset often postprandial particularly with fatty meals

›Duration greater than 6 hours distinguishes from biliary colic

›Radiation to right shoulder or scapula

›Nausea and vomiting

›Associated anorexia

›Bilious vomiting suggests common bile duct involvement

›Fever

›Low-grade in uncomplicated cases

›High fever with rigors suggests Grade II or III

Risk factors

›Demographic and metabolic risk

›The 5 Fs mnemonic

›Female sex

›Fertile age group

›Fat (obesity)

›Forty years of age

›Fair complexion

›Metabolic risk factors

›Diabetes mellitus

›Rapid weight loss or bariatric surgery

›Total parenteral nutrition use

›Hyperlipidemia

Acalculous cholecystitis risk

›Critically ill patient context

›ICU admission for non-biliary illness

03Physical Exam/exam33

Abdominal examination

›Murphy sign

›Technique: deep palpation in right upper quadrant during inspiration

›Sensitivity 65% specificity 87%

›Positive when patient arrests inspiration due to pain

›Sonographic Murphy sign on ultrasound probe

›Higher specificity when combined with gallstones

›Negative predictive value 95% if absent with normal ultrasound

›Peritoneal findings

›Guarding and rigidity

›Suggests perforation or gangrenous cholecystitis

›Involuntary guarding warrants emergent surgical consultation

›Rebound tenderness

›Rovsing sign if present

›Consider appendicitis in differential

Vital signs

›Hemodynamic assessment

›Fever threshold 38.5 degrees C associated with Grade II or III

›Hypothermia in sepsis suggests severe disease

›Tachycardia greater than 100 beats per minute

›Hypotension defines Grade III Tokyo

›SBP less than 90 mmHg or MAP less than 65 mmHg

›Orthostatic assessment if borderline

Systemic assessment

›Jaundice and scleral icterus

›Suggests Mirizzi syndrome or choledocholithiasis

›Bilirubin elevation

›Requires MRCP or ERCP evaluation

04Differential Diagnosis/ddx45

Hepatobiliary causes

›Biliary colic

›ICD-10: K80.20

›Pain lasts less than 6 hours and resolves spontaneously

›No fever or leukocytosis

›No wall thickening on ultrasound

›Choledocholithiasis

›ICD-10: K80.50

›Elevated bilirubin and alkaline phosphatase

›Common bile duct dilation on ultrasound

›Requires ERCP

›Ascending cholangitis

›ICD-10: K83.0

›Charcot triad: fever jaundice RUQ pain

›Reynolds pentad adds shock and altered mentation

›Emergent ERCP or biliary drainage

Gastric and pancreatic causes

›Acute pancreatitis

›ICD-10: K85.9

›Epigastric pain radiating to back

›Lipase elevation greater than 3x upper limit of normal

›Gallstone pancreatitis in 40% of cases

›Peptic ulcer disease

›ICD-10: K27.9

›Epigastric pain without fever

›History of NSAID or H pylori

›Perforated ulcer with free air on imaging

›Gastritis

05Laboratory Tests/lt55

Inflammatory markers

›White blood cell count

›Leukocytosis greater than 10 x 10^9/l in 60-70% of cases

›Greater than 18 x 10^9/l suggests Grade II or III

›Normal WBC does not exclude cholecystitis especially in elderly

›Left shift with bands

›Indicates bacterial superinfection

›Correlates with Tokyo Grade severity

›C-reactive protein

›CRP greater than 3 mg/dl supports Grade II or III

›Used in Tokyo Guidelines 2018 for severity stratification

›Serial CRP useful to assess treatment response

›Procalcitonin

›Elevation suggests bacterial infection and bacteremia risk

›Guides antibiotic duration decisions

Liver function tests

›Bilirubin

›Total bilirubin elevation suggests choledocholithiasis

›Greater than 34 umol/l warrants MRCP evaluation

›Isolated modest elevation may occur in uncomplicated cholecystitis

›Direct versus indirect fraction

›Predominantly direct hyperbilirubinemia in obstruction

›Aids differentiation from hemolysis

›Alkaline phosphatase and GGT

›Elevation indicates biliary obstruction pattern

›GGT more sensitive for biliary origin

›Combined elevation with bilirubin is high specificity for CBD stone

›AST and ALT

06Diagnostic Tests/dt125

Scoring Systems

›Tokyo Guidelines 2018 severity grading

›Grade I mild cholecystitis

›No organ dysfunction

›Mild local inflammation

›Responds to initial medical management

›Grade II moderate cholecystitis

›WBC greater than 18 x 10^9/l

›Palpable tender mass in RUQ

›Duration of symptoms greater than 72 hours

›Marked local inflammation including pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis

›Grade III severe cholecystitis

›Cardiovascular dysfunction: hypotension requiring vasopressors

›Neurologic dysfunction: altered consciousness

›Respiratory dysfunction: PaO2/FiO2 ratio less than 300

›Renal dysfunction: oliguria or creatinine greater than 176 umol/l

›Hepatic dysfunction: INR greater than 1.5

›Hematologic dysfunction: platelet count less than 100 x 10^9/l

›Tokyo Guidelines 2018 diagnostic criteria

›Local signs of inflammation (A criteria)

›Murphy sign

›RUQ mass tenderness or pain

›Systemic signs (B criteria)

›Fever greater than 38 degrees C

›CRP greater than 3 mg/dl

›WBC greater than 10 x 10^9/l

›Imaging findings (C criteria)

›Characteristic findings on ultrasound or CT

›Suspected diagnosis: one from A plus one from B

›Definite diagnosis: one from A plus one from B plus C

Ultrasound

›First-line imaging modality

›Sensitivity 81% specificity 83% for acute cholecystitis

›ACEP Level B recommendation as initial imaging

›No ionizing radiation safe in pregnancy

›Technical advantages

›Bedside availability for unstable patients

›Real-time sonographic Murphy sign elicitation

›Color Doppler for vascular assessment

›Diagnostic findings

›Gallstones with posterior acoustic shadowing

›Present in 90-95% of calculous cholecystitis

›Mobile versus impacted in cystic duct

›Gallbladder wall thickening

›Greater than 3 mm is abnormal

›Sonographic halo sign: hypoechoic layer within wall

›Pericholecystic fluid

›Indicates severe local inflammation

›Suggests perforation or Grade II-III disease

›Gallbladder distension

›Transverse diameter greater than 4 cm

›Longitudinal diameter greater than 8 cm

›Common bile duct diameter

›Normal less than 6 mm (up to 8 mm post-cholecystectomy)

›Greater than 6 mm suggests choledocholithiasis

›Limitations

›Operator dependent

›Body habitus and bowel gas limit visualization

›Acalculous cholecystitis more challenging to diagnose

›When negative but high clinical suspicion

›Proceed to HIDA scan or CT

›Consider endoscopic ultrasound for equivocal cases

CT

›Indications

›Negative or equivocal ultrasound with high suspicion

›Evaluation for complications: perforation, abscess, emphysema

›Surgical planning in complex cases

›Sensitivity 94% specificity 59% for cholecystitis

›Superior to ultrasound for detecting complications

›Preferred in emergency setting when HIDA not available

›Protocol

›CT abdomen and pelvis with IV contrast

›Portal venous phase for optimal gallbladder wall assessment

›Oral contrast optional and usually not needed

›Non-contrast CT

›Detects gallstones in only 15-20% (most are isodense to bile)

›Detects emphysematous change and perforation without contrast

›CT findings

›Gallbladder wall thickening greater than 3 mm

›Pericholecystic fat stranding

›Mural enhancement with IV contrast

›Pericholecystic fluid

›Subserosal edema

›Hepatic subcapsular edema in severe cases

›Emphysematous changes

›Gas within gallbladder wall

›Gas within gallbladder lumen

›Clostridial species infection

›Perforation findings

›Disruption of gallbladder wall continuity

›Free intraperitoneal fluid or air

›Pericholecystic abscess

MRI

›Indications

›Pregnancy when ultrasound non-diagnostic

›No ionizing radiation

›Excellent soft tissue characterization

›Evaluation for choledocholithiasis

›MRCP protocol without gadolinium

›Sensitivity 92% specificity 97% for CBD stones

›Complex hepatobiliary pathology

›Mirizzi syndrome evaluation

›Intrahepatic biliary anatomy before surgery

›MRCP specific findings

›Common bile duct stones as low signal filling defects

›Intraductal stones smaller than 3 mm may be missed

›Dynamic sequences improve small stone detection

›Biliary anatomy mapping

›Variant anatomy identification before cholecystectomy

›Cystic duct insertion level and course

›Limitations

›Limited availability in acute setting

›Longer acquisition time than CT

›Contraindicated with certain pacemakers and metallic implants

›Motion artifact from patient discomfort

›Adequate analgesia required for image quality

Scoring Systems (continued 1)

›HIDA scan (hepatobiliary iminodiacetic acid scintigraphy)

›Gold standard when ultrasound equivocal

›Sensitivity 97% specificity 90% for acute cholecystitis

›Cystic duct obstruction demonstrated by non-visualization of gallbladder

›Technique

›IV technetium-99m labeled iminodiacetic acid derivative

›Images at 30 60 and 120 minutes

›Morphine augmentation if gallbladder not visualized at 60 minutes

›Limitations

›Not available 24 hours in many centers

›3-4 hour study duration

›False positive in prolonged fasting or TPN use

›Radiation exposure limits use in pregnancy

07Disposition/dispo49

Admission criteria

›All confirmed cholecystitis requires admission

›Grade I: surgical ward admission

›IV antibiotics and analgesia

›Early laparoscopic cholecystectomy within 1-3 days

›Monitoring for clinical deterioration

›Grade II: surgical ward with close monitoring

›IV antibiotics and supportive care

›Early or delayed surgery based on local expertise

›Reassessment at 24 and 48 hours

›Grade III: ICU or step-down unit

›Organ support as required

›Interventional radiology or emergency surgery consultation

›Multidisciplinary team approach

Surgical consultation timing

›Early cholecystectomy indications

›Tokyo Grade I and Grade II within 72 hours

›Within 1-3 days of diagnosis

›Up to 7-10 days from symptom onset still acceptable

›Associated with fewer composite complications: 11.8% versus 34.4% for late surgery

›Benefits of early versus delayed surgery

›Shorter hospital stay: 5.4 versus 10.0 days

›Lower hospital costs

›Avoids recurrence in delayed management group

Transfer criteria

›Transfer indications

›Grade III requiring ICU resources not available at initial center

›Vasopressor support

08Treatment/t117

Initial medical management

›NPO and fluid resuscitation

›Nothing by mouth

›Surgical candidacy preservation

›Reduces gallbladder stimulation

›IV fluid therapy

›Isotonic crystalloid at 125-250 ml/hr

›Bolus 500 ml for dehydration

›Reassess fluid status every 4-6 hours

›Nasogastric decompression

›Indicated for persistent vomiting or ileus

›16-18 Fr nasogastric tube to low continuous suction

›Electrolyte replacement with NG losses

Analgesia

›NSAID analgesia

›Diclofenac 75 mg IM or IV

›ACEP Level B recommendation for biliary pain

›Safe and effective without promoting sphincter of Oddi spasm

›Repeat at 6 hours if required

›Ketorolac 15-30 mg IV

›Alternative NSAID

›Caution in renal impairment: use lower dose

›Maximum 5 days duration

›Opioid analgesia

›Morphine 0.05-0.1 mg/kg IV titrated

›Historical concern for sphincter of Oddi spasm not clinically validated

›Safe to use and does not mask peritoneal findings

›Titrate every 5-10 minutes to pain relief

›Hydromorphone 0.015 mg/kg IV

›Alternative opioid

›Repeat every 3-4 hours as needed

›Multimodal approach

›Acetaminophen 1000 mg IV or oral

›Adjunct to reduce opioid requirement

›Dose reduce for hepatic impairment: 500 mg every 6 hours

›Antiemetics

›Ondansetron 4-8 mg IV for nausea

›Metoclopramide 10 mg IV as alternative

Antibiotic therapy

›Antibiotic indications

›Grade I: antibiotics not universally required

›Use if suspected infection: WBC greater than 12.5 x 10^9/l or temperature greater than 38.5 degrees C

›Perioperative prophylaxis for cholecystectomy

›Grade II and III: broad spectrum antibiotics mandatory

›Initiate within 1 hour of diagnosis

›Class I recommendation for severe cholecystitis

›First-line regimens

›Community-acquired mild-moderate cholecystitis

›Cefazolin 1-2 g IV every 8 hours

›Add metronidazole 500 mg IV every 8 hours for anaerobic coverage

›Duration 3-5 days then oral step-down

›Moderate-severe community-acquired

›Piperacillin-tazobactam 4.5 g IV every 8 hours

›Or ceftriaxone 2 g IV daily plus metronidazole 500 mg IV every 8 hours

›Duration 5-7 days

›Healthcare-associated and severe sepsis

›Meropenem 1 g IV every 8 hours

›Covers ESBL organisms

›De-escalate based on culture and sensitivity

›Add vancomycin 25 mg/kg loading dose if MRSA risk

›Target trough 15-20 mcg/ml

›Adjust for renal function

›Common biliary organisms

›Gram negative enteric organisms

›E coli most common

›Klebsiella pneumoniae

›Gram positive organisms

›Enterococcus faecalis

›Streptococcal species

›Anaerobes

›Bacteroides fragilis

›Clostridium species in emphysematous cholecystitis

Surgical treatment

›Laparoscopic cholecystectomy

›First-line definitive therapy

›Class I recommendation

›Early surgery within 1-3 days preferred over delayed

›Composite complication rate 11.8% versus 34.4% for delayed surgery

›Conversion to open cholecystectomy

›Dense adhesions or unclear anatomy

›Intraoperative complication

›Conversion rate approximately 10-15% for acute cholecystitis

›Intraoperative cholangiogram

›Consider if choledocholithiasis suspected

›Documents normal anatomy before ductal division

›Reduces bile duct injury risk

Percutaneous cholecystostomy

›Indications

›Grade III patients unfit for immediate surgery

›American Society of Anesthesiologists class IV-V

›Active myocardial infarction within 30 days

›Severe coagulopathy

›Bridge to surgery in Grade II high-risk patients

›Reassess surgical candidacy at 6-8 weeks

›30-day interval cholecystectomy preferred

›Procedure details

›Ultrasound or CT guided placement

›Transhepatic route preferred for stable tube positioning

›Transperitoneal route if transhepatic not feasible

›Tube management

›Gravity drainage for 4-6 weeks

›Cholangiogram through tube before removal

›Remove once cystic duct patent and inflammation resolved

›Outcomes

›Postprocedural complication rate 65%

›Higher than laparoscopic cholecystectomy 12%

›Catheter dislodgement, bile leak, bleeding

›Technical success rate greater than 90%

›Clinical improvement within 48-72 hours

›Failure to improve warrants urgent surgery

Endoscopic and EUS-guided drainage

›EUS-guided gallbladder drainage

›Increasingly used in non-surgical candidates

›High technical success rate greater than 90%

›Lower reintervention rate than percutaneous cholecystostomy

›Techniques

›Lumen-apposing metal stent placement

›Transmural access to gallbladder through stomach or duodenum

›Avoids external catheter

›Endoscopic transpapillary drainage

›For selected cases with favorable anatomy

›Stent placed across cystic duct into gallbladder

›No external access required

09Special Populations/sp92

Pregnancy

›Epidemiology and risk

›Second most common non-obstetric surgical emergency in pregnancy

›Appendicitis is most common

›Incidence 1 in 1600 to 1 in 10000 pregnancies

›Risk factors specific to pregnancy

›Elevated estrogen increases biliary cholesterol saturation

›Progesterone reduces gallbladder motility

›Gallstone formation accelerated during pregnancy

›Imaging considerations

›Ultrasound first-line and preferred

›No ionizing radiation

›Adequate for initial diagnosis in most cases

›MRI when ultrasound non-diagnostic

›Gadolinium contrast avoided in pregnancy

›MRCP without contrast for biliary anatomy

›CT avoided unless life-threatening indication

›Radiation exposure to fetus

›Use lowest dose technique if required

›Surgical management in pregnancy

›Early laparoscopic cholecystectomy safe in all trimesters

›Maternal-fetal complication rate 1.6% versus 18.4% for delayed management

›Second trimester preferred for elective cases

›AGA 2024 guideline endorses early surgery

›Laparoscopic technique modifications

›Open Hasson technique for abdominal entry

›Left lateral uterine displacement in third trimester

›Intraabdominal pressure limited to 10-12 mmHg

›Fetal monitoring perioperatively

›Conservative management risks

›Preterm labor risk from recurrent cholecystitis

›Recurrence rate 40-60% if managed non-operatively

›Gallstone pancreatitis risk with delayed management

Geriatric

›Atypical presentation

›Classic features absent in up to 50% of elderly patients

›Fever absent in 30-40%

›Murphy sign less reliable

›Leukocytosis may be absent

›Higher rates of complicated disease at presentation

›Gangrenous cholecystitis more common

›Perforation risk increased

›Delayed presentation due to blunted pain response

›Outcomes and mortality

›Laparoscopic cholecystectomy reduces 2-year mortality

›15.2% mortality with surgery versus 29.3% with non-operative management

›Surgery preferred even in high-risk elderly patients

›Frailty assessment

›Clinical Frailty Scale or equivalent

›Geriatric consultation for comorbidity optimization

›Multidisciplinary team decision-making

›Medication considerations

›NSAID caution in elderly

›Increased GI bleeding risk

›Renal function decline with NSAIDs

›Prefer IV acetaminophen as primary analgesic

›Opioid dose reduction

›25-50% dose reduction in frail elderly

›Increased delirium risk with opioids

›Avoid meperidine in elderly

›Antibiotic dosing adjustments

›Renal function guided dosing

›Aminoglycoside avoidance in reduced eGFR

Pediatrics

›Epidemiology

›Less common than adults

›Prevalence increasing with childhood obesity epidemic

›Hemolytic conditions predispose: sickle cell, hereditary spherocytosis

›Age-specific risk factors

›Adolescent females with oral contraceptives

›Prolonged TPN in neonates and infants

›Ceftriaxone-associated pseudolithiasis

›Clinical features

›Similar to adult presentation in older children

›Younger children may have non-specific abdominal pain

›Vomiting often prominent feature

›Murphy sign reliability decreases with younger age

›Diagnostic approach

›Ultrasound preferred

›No ionizing radiation

›Excellent visualization due to less body habitus interference

›Wall thickening threshold same as adults: greater than 3 mm

›Acalculous cholecystitis more common in children

›Particularly in critically ill or post-surgical patients

›Kawasaki disease association

›Sepsis association

›Treatment in pediatrics

›Laparoscopic cholecystectomy is standard

›Weight-based IV fluid: 10-20 ml/kg isotonic crystalloid

›Analgesia: morphine 0.05-0.1 mg/kg IV every 4 hours as needed

›Antibiotic: cefazolin 25-50 mg/kg IV every 8 hours (max 2 g per dose)

›Acalculous cholecystitis in pediatrics

›Trial of conservative management if hemodynamically stable

›Percutaneous drainage for critically ill with acalculous disease

›Spontaneous resolution in up to 50% with appropriate treatment

10Background/b85

Epidemiology

›Incidence and prevalence

›Gallstone disease affects 10-15% of adults in Western countries

›Acute cholecystitis develops in 1-3% of patients with symptomatic gallstones per year

›Approximately 200000 cases of acute cholecystitis annually in the US

›Gender and age distribution

›Female to male ratio approximately 2:1

›Peak incidence age 40-60 years

›Incidence increases with age

›Acalculous cholecystitis epidemiology

›Represents 5-10% of all acute cholecystitis

›Higher mortality than calculous: 30% versus 5%

›Primarily in critically ill patients

›Risk populations

›ICU patients on prolonged TPN

›Post major surgery or trauma

›HIV infection with CD4 less than 100

›Mortality

›Uncomplicated Grade I: mortality less than 1%

›Grade II: 1-5% with appropriate management

›Grade III: 10-30% dependent on organ failure burden

›Emergency cholecystectomy mortality 3-5 times higher than elective

›Supports early elective surgery over delayed emergency surgery

Pathophysiology

›Calculous cholecystitis mechanism

›Cystic duct obstruction by gallstone

›Occurs in 90-95% of acute cholecystitis cases

›Bile stasis leads to mucosal injury

›Prostaglandin-mediated inflammatory cascade

›Progression of inflammation

›Edematous phase: hours 0-4

›Necrotizing phase: hours 24-72

›Suppurative phase: days 3-7 with potential perforation

›Secondary bacterial infection

›Occurs in 20-50% of cases

›Bacterial invasion of obstructed gallbladder

›Increases perforation and empyema risk

›Acalculous cholecystitis mechanism

›Gallbladder ischemia and stasis

›Splanchnic hypoperfusion in critical illness

›Decreased gallbladder contractility from fasting

›Bile concentration and sludge formation

›Inflammatory mediators

›Cytokine release in systemic inflammation

›Lysolecithin and bile salt toxicity

›Gallbladder microvascular injury

›Gallstone formation

›Cholesterol supersaturation of bile

›Estrogen increases hepatic cholesterol secretion

›Reduced bile salt pool with ileal disease

›Nucleation and crystal formation

›Mucin glycoproteins as nucleating agents

›Gallbladder hypomotility promotes crystal aggregation

Therapeutic Considerations

›Early versus delayed cholecystectomy evidence

›Early surgery within 1-3 days

›Composite complication rate 11.8% versus 34.4% for delayed

›Hospital stay 5.4 versus 10.0 days

›Lower total hospital costs

›JAMA 2022 review supports early surgery as preferred approach

›Surgery timing window

›Up to 7-10 days from symptom onset acceptable

›After 10 days dense adhesions increase conversion rate

›Inflammation peak at 72-96 hours then begins to subside

›Antibiotic therapy evidence

›Duration of antibiotic therapy

›Grade I: perioperative dose only or 3-5 days

›Grade II: 5-7 days

›Grade III: 7-14 days or until source controlled

›Conservative antibiotics alone

›36% readmission rate at 12 months

›Bridge to surgery not definitive therapy

›Surgical Infections 2020 retrospective data

›Non-operative management options

›Percutaneous cholecystostomy

›Complication rate 65% higher than surgical 12%

›Appropriate for non-surgical candidates

›JAMA Surgery 2025 review of indications

›EUS-guided drainage

›Emerging alternative with favorable outcomes

›AGA 2023 practice update supports expanding use

›Avoids external catheter complications

›ICD-10 classification

›K81.0 Acute cholecystitis

›K81.1 Chronic cholecystitis

›K80.00 Calculus of gallbladder with acute cholecystitis without obstruction

›K82.0 Obstruction of gallbladder

›K81.9 Cholecystitis unspecified

11Patient Discharge Instructions/pdi33

copy discharge instructions

›Discharge instructions for acute cholecystitis

›Activity restrictions

›No driving for 24-48 hours after opioid medications

›No heavy lifting greater than 5 kg for 2 weeks after surgery

›Light walking encouraged from day 1 post-surgery

›Diet guidance

›Low-fat diet until definitive surgical treatment

›Avoid fried foods, fatty meats, full-fat dairy

›Small frequent meals

›Adequate hydration 2-3 liters water daily

›Wound care after laparoscopic cholecystectomy

›Keep incision sites dry for 48 hours

›Remove dressings after 48 hours unless instructed otherwise

›Shower allowed after 48 hours

›No bathing or swimming for 2 weeks

›Medications

›Complete full course of oral antibiotics if prescribed

›Acetaminophen 500-1000 mg every 6-8 hours for pain

›Ibuprofen 400 mg with food if no contraindications

›Avoid alcohol while on antibiotics or opioids

›Follow-up appointments

›Surgical follow-up within 1-2 weeks

›GP follow-up within 48-72 hours if discharged without surgery

›Blood work if ordered at follow-up

›Return to emergency department if

›Fever greater than 38.5 degrees C

›Worsening or new abdominal pain

12References/r36

Guidelines and key sources

›Primary evidence base

›Gallaher JR, Charles A. Acute Cholecystitis: A Review. JAMA. 2022

›Comprehensive review: management, outcomes, special populations

›JAMA evidence synthesis supporting early cholecystectomy

›Strasberg SM. Acute Calculous Cholecystitis. NEJM. 2008

›Foundational review of pathophysiology and management

›Landmark reference for surgical timing evidence

›Mencarini L et al. The Diagnosis and Treatment of Acute Cholecystitis. J Clin Med. 2024

›Comprehensive narrative review with practical approach

›Current drug dosing and antibiotic guidance

›Society guidelines

›Tokyo Guidelines 2018 (TG18) for cholecystitis severity grading

›Grade I II III classification system

›Diagnostic criteria and management algorithms

›WSES 2017 Guidelines for Intra-Abdominal Infections

›Antibiotic regimen recommendations

›Sartelli M et al. World J Emerg Surg. 2017

›Sadaka AH, Tseng JF, Itani KMF. Percutaneous Cholecystostomy Drainage. JAMA Surg. 2025

›Current indications for percutaneous drainage

›Outcomes data for non-surgical candidates

›Specialty guidelines

›Patel H, Jepsen J. Gallstone Disease. AAFP. 2024

›Primary care perspective and diagnostic algorithm

›HIDA scan and ultrasound performance characteristics

›AGA Clinical Practice Update on Pregnancy-Related GI Disease. Gastroenterology. 2024

›Kothari S et al.

›Safety of laparoscopic cholecystectomy in pregnancy

Evidence & Review