What is the appropriate management for conditions including cholecystitis, appendicitis, diverticulitis, small bowel obstruction, pancreatitis, and hepatitis?

Management of Acute Abdominal Emergencies

Acute Cholecystitis

Perform laparoscopic cholecystectomy within 72 hours of diagnosis, extending up to 7-10 days from symptom onset maximum, as this approach reduces complications, prevents recurrence, and improves outcomes. 1

Surgical Approach

• Laparoscopic cholecystectomy is the definitive treatment and should be performed as soon as possible after diagnosis 2, 1
• Early surgery (within 7 days) results in shorter hospitalization, lower costs, fewer work days lost, and reduced risk of recurrent gallstone complications 3, 1
• Delaying surgery beyond 10 days significantly increases complication rates and recurrence risk 1
• Percutaneous cholecystostomy is reserved for critically ill patients, those with multiple comorbidities, or patients unfit for surgery 2, 3, 1

Antibiotic Management

• For uncomplicated cholecystitis with adequate source control, no postoperative antibiotics are necessary 1
• For complicated cholecystitis, use broad-spectrum empiric antibiotics: piperacillin-tazobactam, cefotaxime/ceftriaxone/cefepime plus metronidazole, or carbapenems (imipenem, meropenem, ertapenem) 1
• Treat for 4 days in immunocompetent non-critical patients with adequate source control 4
• Extend to 7 days in immunocompromised or critical patients based on clinical response 4

Critical Pitfall

• Continuing antibiotics postoperatively for uncomplicated cholecystitis provides no benefit and promotes resistance 1

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Acute Appendicitis

Perform appendectomy as soon as possible, ideally within 24 hours of diagnosis, using laparoscopic approach whenever feasible. 2

Surgical Management

• Laparoscopic appendectomy is preferred when feasible and not contraindicated 2, 5
• Operative management is safer than conservative treatment, particularly given high rates of complicated appendicitis 2
• In immunocompromised or transplanted patients, surgery should occur within 24 hours due to higher complication rates 2

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Acute Diverticulitis

Uncomplicated diverticulitis warrants trial of medical therapy with bowel rest and IV antibiotics; complicated diverticulitis or failure to improve requires surgical intervention as soon as possible. 2

Medical Management (Uncomplicated)

• Trial of medical therapy includes bowel rest, intravenous antibiotics, and supportive care 2
• Immunocompromised patients (transplant recipients, chronic steroid/immunosuppressant users) have higher incidence and severity 2

Surgical Management (Complicated)

• When complicated diverticulitis occurs or medical therapy fails, surgical intervention is indicated immediately 2
• Hartmann procedure is effective and safe in severely sick immunocompromised patients 2
• Emergency surgery carries higher mortality and morbidity in immunocompromised patients 2
• Damage control approach should be adopted in severely sick patients with physiological derangement 2

Critical Consideration

• Acute left-sided colonic diverticulitis is associated with increased mortality in immunocompromised patients, requiring accurate diagnosis and close follow-up 2

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Small Bowel Obstruction

Obtain CT abdomen/pelvis with IV contrast for rapid diagnosis, as imaging determines management in the majority of cases. 2

Diagnostic Approach

• CT abdomen and pelvis with IV contrast is the preferred imaging modality for acute nonlocalized abdominal pain and suspected obstruction 2
• CT changed the leading diagnosis in 51% of patients and admission decisions in 25% of patients with abdominal pain 2
• Plain radiography has only moderate sensitivity (49%) for bowel obstruction and should not be relied upon 2

Management Considerations

• Laparoscopic lysis of adhesions is increasingly used for small bowel obstruction 5
• Small bowel diverticulitis can mimic other acute inflammatory disorders and requires CT for diagnosis 6

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Acute Pancreatitis

All severe acute pancreatitis cases require HDU or ITU management with full monitoring and systems support; for gallstone pancreatitis with deterioration, perform urgent ERCP within 48 hours. 2

Severity-Based Management

• Severe acute pancreatitis mandates intensive care setting with full monitoring and organ support 2
• Failure to improve within 48 hours despite intensive resuscitation indicates urgent ERCP and sphincterotomy in gallstone pancreatitis 2
• Immediate therapeutic ERCP is required for severe gallstone pancreatitis with deranged liver function tests and cholangitis (fever, rigors, positive blood cultures) 2

Definitive Management of Gallstone Pancreatitis

• Mild gallstone pancreatitis: perform laparoscopic cholecystectomy within 2-4 weeks, preferably during same admission 2
• Severe gallstone pancreatitis: perform cholecystectomy after inflammatory process subsides 2
• ERCP facilities and expertise must be available at any time for common bile duct evaluation, sphincterotomy, and stone extraction or stenting 2

Critical Pitfall

• Delaying cholecystectomy after mild gallstone pancreatitis leads to potentially avoidable recurrent pancreatitis 2

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Hepatitis

Diagnostic Approach

• CT abdomen/pelvis with IV contrast is appropriate for acute nonlocalized abdominal pain with fever to evaluate hepatobiliary disease 2
• Imaging plays an essential role in narrowing differential diagnosis and directing management 2

Management Considerations

• Management depends on specific etiology (viral, alcoholic, drug-induced, autoimmune) identified through laboratory testing and imaging 2
• In the context of acute abdomen with fever, hepatitis may present alongside other pathology requiring multidisciplinary evaluation 2, 7

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General Principles for Acute Abdomen

Imaging Strategy

• CT abdomen and pelvis with IV contrast is the preferred initial imaging for acute nonlocalized abdominal pain with or without fever 2
• Plain radiography has limited sensitivity and should not delay definitive imaging 2
• In elderly patients with acute abdominal pain and fever, imaging is especially critical as laboratory tests may be nonspecific or normal despite serious infection 2

Common Pitfall

• Double pathology can occur (e.g., concurrent acute cholecystitis with appendicitis, small bowel obstruction, or diverticulitis), requiring thorough exploration beyond initial findings 8