What is the management approach for a patient with a positive Murphy's sign indicative of acute cholecystitis?

From the Guidelines

The management of a patient with a positive Murphy's sign indicative of acute cholecystitis typically involves hospitalization, supportive care, antibiotics, and surgical intervention, with early laparoscopic cholecystectomy being the preferred treatment, as it reduces overall hospital stay and decreases the risk of complications, as supported by the 2020 World Society of Emergency Surgery guidelines 1.

Initial Management

Initial management includes:

• NPO (nothing by mouth) status
• Intravenous fluid resuscitation with normal saline or lactated Ringer's solution
• Pain control with medications such as morphine 2-4 mg IV every 4 hours or hydromorphone 0.5-1 mg IV every 4 hours as needed
• Antibiotic therapy should be started promptly with regimens such as piperacillin-tazobactam 3.375 g IV every 6 hours, or a combination of ceftriaxone 1-2 g IV daily plus metronidazole 500 mg IV every 8 hours, typically for 5-7 days depending on clinical response, as recommended by the 2017 WSES guidelines for management of intra-abdominal infections 1

Definitive Treatment

• The definitive treatment is cholecystectomy, preferably laparoscopic, which should be performed within 24-72 hours of diagnosis when possible
• For patients who are poor surgical candidates, percutaneous cholecystostomy tube placement may be considered as a temporizing measure, as discussed in the 2023 AGA clinical practice update on the role of EUS-guided gallbladder drainage in acute cholecystitis 1
• Early surgical intervention is preferred because it reduces overall hospital stay and decreases the risk of complications such as gallbladder perforation, abscess formation, or progression to sepsis

Monitoring and Follow-up

• Patients should be monitored for signs of clinical improvement including decreased pain, resolution of fever, and normalization of white blood cell count
• The use of ultrasound as the initial imaging modality is recommended, as it is accurate in diagnosing or excluding gallstones and can help identify complications of cholecystitis, as stated in the 2019 ACR Appropriateness Criteria for right upper quadrant pain 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, as outlined in the 2010 guidelines for the diagnosis and management of complicated intra-abdominal infection in adults and children 1

From the Research

Management Approach for Acute Cholecystitis

The management approach for a patient with a positive Murphy's sign indicative of acute cholecystitis involves several steps, including:

• Initial assessment and diagnosis, which may involve imaging studies such as ultrasound or CT scans 2
• Medical treatment, including intravenous hydration, antibiotics, bowel rest, and analgesia 2
• Consideration of percutaneous cholecystostomy (PC) as a bridge to surgery or definite management in high-risk patients 3, 4, 5, 6
• Elective laparoscopic cholecystectomy after the patient has recovered from the acute episode 3, 6

Percutaneous Cholecystostomy (PC)

PC is a minimally invasive procedure that involves the insertion of a catheter into the gallbladder to drain bile and relieve obstruction 5. The procedure is typically performed under imaging guidance, such as ultrasound or CT scans. PC has been shown to be a safe and effective treatment for acute cholecystitis in high-risk patients, with a low morbidity and mortality rate 3, 4, 6.

Indications and Contraindications for PC

The indications for PC include:

• Acute cholecystitis in high-risk patients, such as the elderly or those with severe comorbidities 3, 4
• Failure of medical treatment 6
• Contraindications to surgery, such as severe illness or unstable condition 4 The contraindications for PC include:
• Presence of a shunt or other abnormal communication between the gallbladder and the biliary tree 5
• Presence of a gallbladder tumor or other malignancy 5

Outcomes and Complications of PC

The outcomes of PC have been shown to be favorable, with a high success rate and low morbidity 3, 4, 6. The complications of PC include:

• Bile leakage from the gallbladder 4
• Infection or sepsis 5
• Catheter-related complications, such as blockage or dislodgement 5