From the Guidelines
A positive Murphy sign suggests acute cholecystitis and requires prompt evaluation and management, with the next steps including obtaining laboratory tests and imaging studies, and considering laparoscopic cholecystectomy as the definitive treatment, ideally within 24-72 hours of diagnosis if the patient is stable, as recommended by the 2020 World Society of Emergency Surgery guidelines 1. The diagnosis of acute cholecystitis is made on the basis of clinical features such as right upper quadrant pain, fever, and leukocytosis, and is supported by findings from relevant imaging studies, with ultrasound being the investigation of choice in patients suspected of having acute cholecystitis 1. The treatment typically involves hospital admission, nothing by mouth (NPO) status, intravenous fluids, pain management with medications like morphine or hydromorphone, and broad-spectrum antibiotics such as piperacillin-tazobactam 3.375g IV every 6 hours or ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours. For patients who are poor surgical candidates, percutaneous cholecystostomy may be considered, as it can be both diagnostic and therapeutic, and is usually considered safe in hospitalized patients suspected of having acalculous cholecystitis 1. The Italian Council for the Optimization of Antimicrobial Use recommends antibiotic therapy for 4 days in immunocompetent and no critically ill patients if source control is adequate, and up to 7 days based on clinical conditions and inflammation indices if source control is adequate in immunocompromised or critically ill patients 1. Some key points to consider in the management of acute cholecystitis include:
- Early diagnosis and treatment to prevent complications like perforation, gangrene, or sepsis
- The use of laparoscopic cholecystectomy as the definitive treatment, ideally within 24-72 hours of diagnosis if the patient is stable
- The consideration of percutaneous cholecystostomy as an alternative for patients who are poor surgical candidates
- The importance of adequate antibiotic therapy, with the duration of treatment depending on the patient's clinical conditions and inflammation indices.
From the Research
Positive Murphy Sign: Next Steps
A positive Murphy sign is a clinical indication of acute cholecystitis, which is diagnosed in approximately 200,000 people in the US each year 2. The next steps in managing a patient with a positive Murphy sign include:
- Diagnostic imaging: Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis 2.
- Laboratory tests: To rule out other causes of abdominal pain and to assess the severity of the disease.
- Antibiotic therapy: May be initiated empirically, considering the severity of the clinical manifestations, the onset of the infection, and the penetration of the drug into the bile 3.
- Surgical intervention: Early laparoscopic cholecystectomy (within 1-3 days of diagnosis) is associated with improved patient outcomes, including fewer composite postoperative complications and a shorter length of hospital stay 2.
Treatment Options
The treatment options for acute cholecystitis include:
- Laparoscopic cholecystectomy: The first-line therapy for acute cholecystitis in most patient populations 2, 4.
- Percutaneous cholecystostomy: An effective therapy for patients with an exceptionally high perioperative risk, but associated with higher rates of postprocedural complications compared to laparoscopic cholecystectomy 2.
- Antibiotic therapy: Plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis 3.
- Supportive care: May be sufficient for some patients with acute calculous cholecystitis, but the use of antibiotics is not indicated for conservative management 5.