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Acute Cholecystitis

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Acute Cholecystitis

🃏 Order set for Acute Cholecystitis

  • Tokyo Guidelines 2018 severity grading: Grade I (mild: no organ dysfunction), Grade II (moderate: local complications — pericholecystic abscess, emphysematous, gangrenous), Grade III (severe: organ dysfunction)
  • Diagnosis criteria (TG18): Local (RUQ pain/tenderness, Murphy’s sign, RUQ mass) + Systemic (fever, elevated CRP/WBC) + Imaging (US: gallbladder wall thickening >4mm, pericholecystic fluid, stones)
  • Choledocholithiasis DDx: elevated ALP/GGT, dilated CBD >6mm on US → ERCP ถ้า confirmed
  • Gangrenous/emphysematous cholecystitis: DM risk, gas in gallbladder wall (CT/US), urgent surgery
  • Cholangitis signs (Charcot’s triad): fever + jaundice + RUQ pain → ERCP emergency

🕐 One-Day Orders

🔬 Investigation

  • CBC — leukocytosis; WBC >18,000 = severe/gangrenous risk
  • LFT (AST, ALT, ALP, GGT, bilirubin) — cholestasis pattern
  • BUN, Cr, electrolytes — sepsis/AKI
  • Amylase/Lipase — gallstone pancreatitis DDx
  • US abdomen — gallstones, GB wall thickening, Murphy’s sign US, CBD dilation
  • CRP — severity marker
  • Blood culture x2 — ถ้า fever/chills/hemodynamic instability
  • Blood group + crossmatch ก่อน OR

💊 Medication

  • NPO + IV NSS hydration 1-2 L
  • IV ATB:
    • Grade I/II: Ceftriaxone 2 g IV OD + Metronidazole 500 mg IV q8h หรือ Ampicillin-sulbactam
    • Grade III: Pip-Tazo 4.5 g IV q6h หรือ Meropenem ถ้า severe sepsis
  • Analgesia: Paracetamol 1 g IV q6h; Tramadol 50-100 mg IV q6h PRN; Buscopan 20 mg IV PRN (antispasmodic)
  • Surgical consult — laparoscopic cholecystectomy (early preferred, TG18)

🔁 Continuous Orders

🔬 Investigation

  • CBC, LFT, CRP day 2-3 — response to ATB
  • MRCP/CT ถ้า suspected CBD stone หรือ US inconclusive
  • Pathology GB specimen post-op

💊 Medication

  • IV ATB → PO switch ถ้า improving + tolerating oral:
    • Amoxicillin-clavulanate 625 mg q8h; total ATB 5-7 วัน
  • [Grade I — early cholecystectomy within 72h preferred] (TG18, lower complication rate)
  • [Grade II — early ถ้า surgeon skilled; delayed acceptable]
  • [Grade III — stabilize first: ATB + drainage (percutaneous cholecystostomy); elective surgery later]
  • ถ้า cholangitis: ERCP biliary drainage ก่อน → cholecystectomy ภายหลัง

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