Гострий холецистит

Statement 1.4 Evidence on the diagnostic accuracy of computed tomography (CT) is scarce. While diagnostic accuracy of magnetic resonance imaging (MRI) might be comparable to that of AUS, insufficient data are available to support it. Hepatobiliary iminodiacetic acid scan (HIDA scan) has the highest sensitivity and specificity for acute cholecystitis, although its scarce availability, long time required to perform the test and exposure to ionizing radiation limit its use (LoE 2 GoRB)

Statement 2.4 Antibiotics should be suggested as supportive care; they are effective in treating the first episode of ACC but a high rate of relapse can be expected. Surgery is more effective than antibiotics alone in the treatment of ACC. (LoE 2 GoR C)

Statement 2.5 Cholecystectomy is the gold standard for treatment of ACC (LoE 3 GoR C) 

Statement 2.6 If surgery is not available, medications such as antibiotics and analgesia should be prescribed and the patients should be referred to a surgical centre (depending upon the general condition) due to the high rate of gallstone-related events (LoE 5 GoR D)

Statement 3.1 Patients with uncomplicated cholecystitis can be treated without post-operative antibiotics when the focus of infection is controlled by cholecystectomy (LoE 1 GoR B)

French centres for grade I or II ACC and who received 2 g of amoxicillin plus clavulanic acid three times a day and once at the time of surgery were randomized after surgery to an open-label, non-inferiority, randomized clinical trial between May 2010 and August 2012

Statement 3.2 In complicated acute cholecystitis, the antimicrobial regimens depend on presumed pathogens involved and risk factors for major resistance patterns (LoE 3 GoR B)

The principles of empiric antibiotic treatment should be defined according to the most frequently isolated microbes, always taking into consideration the local trend of antibiotic resistance. Organisms most often isolated in biliary infections are the gram-negative aerobes, Escherichia coli and Klebsiella pneumonia and anaerobes, especially Bacteroides fragilis.

 Piperacillin/tazobactam (4.8) Ceftriaxone (0.75)

Tigecycline (> 10) Cefotaxime (0.23)

Amoxicillin/clavulanate (1.1) Meropenem (0.38)

Ciprofloxacin (> 5) Ceftazidime (0.18)

Ampicillin/Sulbactam (2.4) Vancomycin (0.41)

Cefepime (2.04) Amikacin (0.54)

Levofloxacin (1.6) Gentamicin (0.30)

Penicillin “G” (>5)

Imipenem (1.01)

Statement 4.1 Patient’s age above 80 in ACC is a risk factor for worse clinical behaviour, morbidity and mortality.

1) Beta-lactam/beta-lactamase inhibitor combinations based regimens

AMOXICILLIN/CLAVULANATE (in stable patients)

TICARCILLIN/CLAVULANATE (in stable patients)

PIPERACILLIN/TAZOBACTAM (in unstable patients)

2) Cephalosporins based regimens

CEFTRIAZONE + METRANIDAZOLE (in stable patients)

CEFEPIME + METRANIDAZOLE (in stable patients)

CEFTAZIDIME + METRANIDAZOLE (in stable patients)

CEFOZOPRAM + METRANIDAZOLE (in stable patients)

3) Carbapenem based regimens

ERTAPENEM (in stable patients)

IMIPENEM/CILASTATIN (only in unstable patients)

MEROPENEM (only in unstable patients)

DORIPENEM (only in unstable patients)

4) Fluoroquinolone based regimens (In case of allergy to beta-lactams)

CIPROFLOXACIN + METRONIDAZOLE (only in stable patients)

LEVOFLOXACIN + METRONIDAZOLE (only in stable patients)

MOXIFLOXACIN (only in stable patients)

5) Glycylcycline based regimen

TIGECYCLINE (in stable patients if risk factors for ESBLs)

TIGECYCLINE + PIPERACILLIN/TAZOBACTAM (in stable patients)

IMIPENEM/CILASTATIN +/- TEICOPLANIN (only in unstable patients)

MEROPENEM +/- TEICOPLANIN (only in unstable patients)

DORIPENEM +/- TEICOPLANIN (only in unstable patients)

Statement 4.2 The co-existence of diabetes mellitus does not contraindicate urgent surgery but must be re-considered as a part of the overall patient comorbidity (LoE 3 GoR C)

Statement 4.3 Currently, there is no evidence of any scores in identifying patient’s risk in surgery for ACC. ASA, POSSUM and APACHE II are correlated to surgical risk in patients with gallbladder perforation, higher accuracy being for APACHE II. However, APACHE II is built to predict morbidity and mortality in the patients admitted to ICU: its use as a preoperative score should be considered as an extension usage from the original concept. (LoE 4 GoR C). Therefore, prospective and multicentre studies to compare different risk factors and scores are necessary

Statement 5.1 Early laparoscopic cholecystectomy is preferable to delayed laparoscopic cholecystectomy in patients with ACC as long as it is completed within 10 days of onset of symptoms (LoE 1 GoR A)

Statement 5.2 Laparoscopic cholecystectomy should not be offered for patients beyond 10 days from the onset of symptoms unless symptoms suggestive of worsening peritonitis or sepsis warrant an emergency surgical intervention. In people with more than 10 days of symptoms, delaying cholecystectomy for 45 days is better than immediate surgery (LoE 2 GoR B)

Statement 6.1 In ACC, a laparoscopic approach should initially, be attempted except in case of absolute anaesthesiology contraindications or septic shock (LoE 2 GoR B)

Statement 6.3 Among high-risk patients, in those with Child A and B cirrhosis, advanced age >80, or pregnant women, laparoscopic cholecystectomy for ACC is feasible and safe (LoE 3 GoR C)

Diagnosis 1.1 4 C There is no single clinical or laboratory finding with sufficient diagnostic accuracy to establish or exclude

acute cholecystitis. Combination of detailed history, complete clinical examination, and laboratory tests

may strongly support the diagnosis of ACC

1.2 2 B Abdominal ultrasound (AUS) is the preferred initial imaging technique for patients who are clinically

suspected to have ACC because of its lower cost, better availability, lack of invasiveness, and high

accuracy for gallbladder stones.

1.3 3 C exploration is a fairly reliable investigation method but its sensitivity and specificity for diagnosing ACC

may be relatively low according to the adopted AUS criteria.

1.4 2 B Evidence on the diagnostic accuracy of computed tomogram (CT) is scarce. While diagnostic accuracy of

magnetic resonance imaging (MRI) might be comparable to that of AUS, insufficient data are available to

support this. Hepatobiliary iminodiacetic acid scan (HIDA scan) has the highest sensitivity and specificity

for AC, although its scarce availability, long time required to perform the test, and exposure to ionizing

radiation limit its use.

1.5 4 C Combining clinical, laboratory and imaging investigations is recommended, although the best

combination is not yet known.

Treatment 2.1 2 B There is no role for gallstones dissolution, drugs or extra-corporeal shock wave lithotripsy (ESWL) or a

combination in the setting of ACC.

2.2 4 C Since there are no reports on surgical gallstone removal in the setting of ACC, surgery in the form of

cholecystectomy remains the main option

2.3 3 C Surgery is superior to observation of ACC in the clinical outcome and shows some cost-effectiveness

advantages due to the gallstone-related complications and to the high rate of readmission and surgery in

the observation group

2.4 2 C Antibiotics should be suggested as supportive care; they are effective in treating the first episode of ACC

but a high rate of relapse can be expected. Surgery is more effective than antibiotics alone in the

treatment of ACC.

2.5 3 C Cholecystectomy is the gold standard for treatment of ACC.

2.6 5 D If surgery is not available, medications such as antibiotics and analgesic should be prescribed and the

patients should be referred to a surgical center (depending upon the general condition) due to the high

rate of gallstone-related events.

Antibiotics 3.1 1 B Patients with uncomplicated cholecystitis can be treated without post-operative antibiotics when the

focus of infection is controlled by cholecystectomy

3.2 3 B In complicated cholecystitis, the antimicrobial regimens depend on presumed pathogens involved and

risk factors for major resistance patterns

3.3 3 C The results of microbiological analysis are helpful in designing targeted therapeutic strategies for

individual patients to customize antibiotic treatment and ensure adequate antimicrobial coverage in

patients with complicated cholecystitis and at high risk for antimicrobial resistance.

High risk patients 4.1 3 B Patient’s age above 80 in ACC is a risk factor for worse clinical behaviour, morbidity and mortality.

4.2 3 C The co-existence of diabetes mellitus does not contraindicate urgent surgery but must be re-considered

as a part of the overall patient comorbidity.

4.3 4 C Currently, there is no evidence of any scores in identifying patient’s risk in surgery for ACC. ASA, POSSUM

and APACHE II are correlated to surgical risk in patients with gallbladder perforation, higher accuracy

being for APACHE II. However, APACHE II is built to predict morbidity and mortality in the patients

admitted to ICU: its use as a preoperative score should be considered as an extension usage from the

original concept. Therefore, prospective and multicentre studies to compare different risk factors and

scores are necessary

Timing 5.1 1 A ELC is preferable to DLC in patients with ACC as long as it is completed within 10 days of onset of

symptoms.

5.2 2 B ELC should not be offered for patients beyond 10 days from the onset of symptoms unless symptoms

suggestive of worsening peritonitis or sepsis warrant an emergency surgical intervention. In people with

more than 10 days of symptoms, delaying cholecystectomy for 45 days is better than immediate surgery.

5.3 1 A ELC should be performed as soon as possible but can be performed up to 10 days of onset of

symptoms. However, it should be noted that earlier surgery is associated with shorter hospital stay and

fewer complications.