TREATMENT

All patients are likely to need pain control. Morphine

(0.1 mglkg) N or hydromorphone (0.0125 mgj kg N) are

common choices. Antiemetics are also helpful, with

common regimens being ondansetron 4-8 mg IV, pro ­

methazine 12.5-25 mg N or intramuscularly, or metoclo ­

prarnide 10 mg N. If vomiting has been prolonged, then

fluid resuscitation at 1 0-20 mL/kg is indicated, unless there

is a concern for volume overload (history of congestive

heart failure, end-stage renal disease). Patients should be

made NPO (nothing by mouth) until it is clear they will

not need surgery.

Surgical consultation is necessary when the diagnosis of

acute cholecystitis is established. Cholecystectomy is usu ­

ally performed within 48-72 hours. If testing is equivocal,

then admission for further work-up is appropriate.

Consultation with a GI specialist is necessary for choledocholithiasis to facilitate timely endoscopic retrograde cholangiopancreatography and sphincterotomy.

There is no clear role for antibiotics in uncomplicated

cholecystitis. If there are signs of infection (leukocytosis,

fever), then antimicrobial coverage with a second-generation

cephalosporin or quinolone with metronidazole is appro ­

priate. If the patient presents with sepsis or is at risk to

develop sepsis (elderly, immune system c ompromise, highrisk presentation such as ascending cholangitis, emphysematous cholecystitis), then broad-spectrum antibiotics

should be started promptly. The antibiotic regimen should

cover both gram-positive and gram-negative organisms.

Antibiotic choices include piperacillin- tazobactam 3.375 g N

and vancomycin 1 g N, or in penicillin allergic patients,

ciprofloxacin 400 mg N, metronidazole 500 mg N, and

vancomycin 1 g N.

DISPOSITION

� Admission

Patients with acute cholecystitis should be admitted to a

surgical service. Patients with sepsis or severe disease

should be admitted to an intensive care unit setting.

Admission should also be strongly considered for patients

with persistent symptoms but without definitive evidence

of acute cholecystitis, as testing can be normal early in the

course of the disease.

� Discharge

Patients with biliary colic can be discharged home if their

pain has resolved, testing is normal, and they can tolerate

oral fluids. They should be told to return for persistent

symptoms, more severe pain, or fever. Outpatient follow

up should include referral to a general surgeon.

SUGGESTED READING

Atilla R, Oktay C. Pancreatitis and cholecystitis. In: Tintinalli

JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler

GD. Tintinalli's Emergency Medicine: A Comprehensive

Study Guide. 7th ed. New York, NY: McGraw-Hill, 20 1 1,

pp. 558-566.

Barie PS, Eachempati SR. Acute acalculous cholecystitis.

Gastroenterol Clin North Am. 2010;39:343-357.

Fox JC, Scruggs WP. Ultrasound Guide for Emergency Physicians:

An Introduction. 2008.