Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 7 Sept 2026Clinical review pending
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Complicated gallbladder infection
Hypotension, confusion, peritonism, organ dysfunction or imaging evidence of gangrene, perforation or emphysematous change indicates severe or complicated cholecystitis.
Action: Start ABCDE resuscitation, obtain cultures when indicated, give locally selected intravenous antibiotics, and secure urgent senior surgical, anaesthetic and radiological input for source control.
Synopsis
Recognise acute gallbladder inflammation, confirm the diagnosis without delaying resuscitation, and plan early laparoscopic source control with a safe alternative for patients who cannot undergo surgery.
Suspect acute cholecystitis when right-upper-quadrant pain persists and is accompanied by local tenderness, fever or an inflammatory response.
Use liver tests and ultrasound early, but integrate imaging with the clinical picture because no isolated sign is definitive.
Resuscitate dehydration and sepsis while providing analgesia, antiemetic treatment and thromboembolism prevention appropriate to the patient.
Key red flags
Generalised guarding, shock or free gas suggests perforation and demands immediate surgical reassessment.
New jaundice or sepsis raises concern for common-duct obstruction and cholangitis in addition to gallbladder inflammation.
Complicated disease
Peritonism, palpable mass, shock or gas in the gallbladder wall suggests gangrene, perforation, empyema or emphysematous infection.
Investigation priorities
01
Full blood count and CRPFirst step
Measure the inflammatory response and establish a trajectory.
Management branches
Worked case: early source controlMove from diagnosis to theatre
An adult has eighteen hours of right-upper-quadrant pain, fever, neutrophilia and ultrasound evidence of stones, thickened gallbladder wall and local fluid without duct dilatation.
Resuscitate, provide analgesia and assess anaesthetic and sepsis risk while obtaining a complete history of anticoagulants, comorbidity and previous attacks.
Diagnose acute calculous cholecystitis from the concordant clinical, laboratory and ultrasound pattern; lack of jaundice makes common-duct obstruction less likely but does not remove all uncertainty.
Key medicines
Co-amoxiclav for infected acute cholecystitis: current DBTH adult exampleFor an adult covered by the Doncaster and Bassetlaw Teaching Hospitals September 2025 protocol, give co-amoxiclav 1.2 g intravenously every 8 hours. Review at 48–72 hours and, if improving and absorbing oral treatment, switch to 625 mg orally every 8 hours; the total intravenous-plus-oral course is 5–7 days according to severity and progress, shortened or narrowed when source control and cultures permit. Under the same DBTH acute cholecystitis/cholangitis protocol, if the patient is older than 65 years AND received co-amoxiclav or a cephalosporin in the preceding 2 weeks, use piperacillin/tazobactam 4 g/0.5 g (4.5 g) by intravenous infusion every 8 hours instead, then de-escalate to an appropriate oral antibiotic from cultures or Infection Team advice; the same 5–7-day total course is governed by severity and progress.This named local example applies to adults without penicillin hypersensitivity or previous co-amoxiclav-associated jaundice or hepatic dysfunction. Check renal function before dosing: the current 1,000/200 mg intravenous SmPC uses an initial 1,000/200 mg then 500/100 mg every 12 hours when creatinine clearance is 10–30 mL/min, or every 24 hours below 10 mL/min; seek pharmacy advice for oral step-down. Monitor hepatic function and use the hospital allergy pathway or infection-team advice instead of co-amoxiclav after a serious beta-lactam reaction. For piperacillin/tazobactam, the current SmPC specifies infusion over 30 minutes, no renal change above 40 mL/min, 4 g/0.5 g every 8 hours as the maximum at creatinine clearance 20–40 mL/min, and 4 g/0.5 g every 12 hours below 20 mL/min. Avoid it after penicillin hypersensitivity or a severe immediate reaction to another beta-lactam.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 7 Sept 2026; clinical approval remains outstanding.