From the Guidelines
The management of acute cholecystitis with a positive Murphy sign involves early laparoscopic cholecystectomy, which should be performed within 24-72 hours of diagnosis in most cases, as it reduces overall hospital stay and complication rates 1.
Initial Management
Initial management includes:
- NPO status (nothing by mouth)
- IV fluid resuscitation
- Pain control with medications like morphine or hydromorphone
- Antiemetics such as ondansetron 4mg IV every 8 hours as needed
- Empiric antibiotic therapy should be started promptly with regimens such as piperacillin-tazobactam 3.375g IV every 6 hours, or a combination of ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours, typically for 5-7 days
Definitive Treatment
Definitive treatment is cholecystectomy, preferably laparoscopic, which is considered the recommended treatment for patients who are fit to undergo surgery 1.
- Early laparoscopic cholecystectomy is safe and effective, and it should be attempted only by experienced surgeons 1.
- For patients who are poor surgical candidates due to severe comorbidities, percutaneous cholecystostomy tube placement may be considered as a temporizing measure 1.
Special Considerations
- In elderly patients, laparoscopic approach should always be attempted at first, except in case of absolute anesthetic contraindications and septic shock 1.
- Percutaneous cholecystostomy can be considered in the treatment of acute cholecystitis patients who are deemed unfit for surgery 1.
- The evaluation of the risk for elderly patient with acute cholecystitis should include mortality rate, rate of gallstone-related disease relapse, age-related life expectancy, and patient frailty evaluation by the use of frailty scores 1.
From the Research
Management of Acute Cholecystitis
The management of a patient with a positive Murphy sign indicating acute cholecystitis involves several key components:
- Early laparoscopic cholecystectomy (ELC) is considered the best treatment for acute cholecystitis, with the optimal timeframe for performing ELC being within 72 hours from diagnosis 2.
- Before ELC, the patient's medical management comprises fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics 2, 3.
- Concomitant conditions such as choledocholithiasis, cholangitis, biliary pancreatitis, or systemic complications must be recognized and adequately treated 2.
- In patients who are not eligible for ELC, it is suggested to delay surgery at least 6 weeks after the clinical presentation 2.
- Critically ill patients who are unfit for surgery may require rescue treatments, such as percutaneous or endoscopic gallbladder drainage (GBD) 2, 4, 5.
Special Considerations
- A particular treatment approach should be applied to special populations such as pregnant women, cirrhotic, and elderly patients 2, 5.
- In elderly patients or patients with significant comorbidity, operational risks may still be high, making cholecystectomy inappropriate, and alternative treatments such as gallstone removal using the percutaneous tract or endoscopy may be considered 4.
- During pregnancy, early laparoscopic cholecystectomy is associated with a lower risk of maternal-fetal complications and is recommended during all trimesters 5.
Diagnostic Approaches
- Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis 5.
- When an ultrasound result does not provide a definitive diagnosis, hepatobiliary scintigraphy is the gold standard diagnostic test 5.
- A positive sonographic Murphy sign strongly suggests the diagnosis of acute cholecystitis 6.