Treatment of Acute Calculous Cholecystitis with Ascending Cholangitis or High-Risk Common Bile Duct Stones
This protocol applies to patients with acute calculous cholecystitis who present with one or more high-risk indicators for common bile duct stones (CBDS): confirmed CBDS on abdominal ultrasound, ascending cholangitis, or a total serum bilirubin greater than 4 mg/dl.
Clinical Scenario
Patients with acute calculous cholecystitis and any of the above high-risk features require prompt assessment for bile duct involvement. Evidence of CBDS on abdominal ultrasound or concurrent ascending cholangitis places patients directly in the high-risk category, warranting an expedited pathway that addresses both the gallbladder and the common bile duct.
Treatment Approach
The recommended strategy combines laparoscopic cholecystectomy with clearance of common bile duct stones. Removal of CBDS may be performed through surgical or endoscopic means — the full protocol specifies which approaches apply and under what circumstances.
References
DOI: 10.1186/s13017-020-00336-x
- Patients with high risk of CBDS should undergo preoperative diagnostic and therapeutic ERCP.
- Only patients with evidence of CBDS at abdominal US should be considered at high risk of CBDS and should undergo diagnostic and therapeutic ERCP directly; patients with total serum bilirubin > 4 mg/dl or enlarged common bile duct diameter at US with concomitant bilirubin level 1.8 to 4 mg/dl should be considered as moderate risk and should undergo second level investigation such as endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP), laparoscopic ultrasound (LUS) or IOC, in order to avoid the complications related to ERCP.
- We recommend laparoscopic cholecystectomy as the first-line treatment for patients with ACC.
- We recommend removing CBDS, either preoperatively, intraoperatively, or postoperatively, according to the local expertise and the availability of several techniques.
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