Acute Cholecystitis Management

Diagnostic Approach

A positive Murphy sign in a patient with right upper quadrant pain, nausea, and vomiting strongly suggests acute cholecystitis and mandates immediate ultrasound imaging followed by early laparoscopic cholecystectomy within 7-10 days of symptom onset, as recommended by the World Journal of Emergency Surgery 1, 2
Ultrasound is the investigation of choice and must be performed immediately in all patients with suspected acute cholecystitis, with a focus on detecting gallstones, distended gallbladder, edematous gallbladder wall, pericholecystic fluid, and gallstones impacted in the cystic duct 1, 2
The sonographic Murphy sign can be elicited during ultrasound but has relatively low specificity 1, 2, 5

Early laparoscopic cholecystectomy within 7-10 days of symptom onset is the definitive treatment for uncomplicated acute cholecystitis, with single-shot antibiotic prophylaxis if early intervention is performed 1, 2
Antibiotic therapy for 2-4 days is recommended if source control is adequate, with options including amoxicillin/clavulanate, eravacycline, or tigecycline 1, 2
For critically ill or immunocompromised patients, piperacillin/tazobactam or eravacycline are recommended, with antibiotic therapy for 4 days in immunocompetent patients and up to 7 days in immunocompromised or critically ill patients 1, 2

Cholecystostomy may be considered for patients with multiple comorbidities who do not show clinical improvement after antibiotic therapy, with antibiotic therapy for 4 days following cholecystostomy 1, 2
Patients with ongoing signs of infection or systemic illness beyond 7 days of antibiotic treatment warrant diagnostic investigation for complications or alternative diagnoses 1, 2