# Acute Cholecystitis (Emergency Referral) - Category: emergency - Review status: reviewed (every claim checked against a document named on this page) - Sources: Acute Cholecystitis - StatPearls, updated 6 July 2025 - https://www.ncbi.nlm.nih.gov/books/NBK459171/ · Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) · Egyptian National Drug Formulary - Antimicrobial 2023 (metronidazole monograph, p306) · Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) - general adult dosage 1 to 2 g intravenously or intramuscularly once daily or divided twice daily, maximum 4 g daily, with community-acquired intra-abdominal infection among the named indications. · Egyptian National Drug Formulary - Antimicrobial 2023 (metronidazole monograph, p306) - intra-abdominal infection, oral or intravenous 500 mg every 8 hours as part of an appropriate combination regimen, for 4 to 7 days following adequate source control. - Verified date: 2026-08 ## Verified against - Acute Cholecystitis - StatPearls, updated 6 July 2025 - https://www.ncbi.nlm.nih.gov/books/NBK459171/ - Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) - Egyptian National Drug Formulary - Antimicrobial 2023 (metronidazole monograph, p306) - Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) - general adult dosage 1 to 2 g intravenously or intramuscularly once daily or divided twice daily, maximum 4 g daily, with community-acquired intra-abdominal infection among the named indications. - Egyptian National Drug Formulary - Antimicrobial 2023 (metronidazole monograph, p306) - intra-abdominal infection, oral or intravenous 500 mg every 8 hours as part of an appropriate combination regimen, for 4 to 7 days following adequate source control. ## Treatment metadata - Ceftriaxone — 1000 mg — injection - Metronidazole — 500 mg — injection - Referral & safety-netting (no drug therapy) ## Complete treatment card ```text ACUTE CHOLECYSTITIS (EMERGENCY REFERRAL) Sources: Acute Cholecystitis - StatPearls, updated 6 July 2025 - https://www.ncbi.nlm.nih.gov/books/NBK459171/ · Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) · Egyptian National Drug Formulary - Antimicrobial 2023 (metronidazole monograph, p306) · Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) - general adult dosage 1 to 2 g intravenously or intramuscularly once daily or divided twice daily, maximum 4 g daily, with community-acquired intra-abdominal infection among the named indications. · Egyptian National Drug Formulary - Antimicrobial 2023 (metronidazole monograph, p306) - intra- abdominal infection, oral or intravenous 500 mg every 8 hours as part of an appropriate combination regimen, for 4 to 7 days following adequate source control. Review status: REVIEWED against 2 sources listed above (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (4) - Worsening right upper abdominal pain with bloating, nausea, vomiting, and trouble tolerating greasy or spicy food develops gradually in the chronic form [abdominal distension · abdominal pain · nausea · right upper quadrant pain · vomiting] - Pain can radiate to the mid-back or right shoulder, and intermittent episodes may go on for years before diagnosis - The acute form has the same symptoms but more severe, and can be confused with a cardiac problem - Attacks often follow eating high-fat food SIGNS - what you find (1) - Murphy's sign, the patient stops breathing in when the examiner presses on the right upper quadrant, is the classic finding [apnoea] TESTS (7) - CBC and metabolic panel can be normal in the chronic form but often show a raised white count and liver enzymes in acute or severe disease - A raised bilirubin raises concern for a stone blocking the common bile duct, though labs can stay normal even in advanced disease - Amylase and lipase are checked to rule out pancreatitis - CT often serves as the first scan in the ER, showing a distended, thick-walled gallbladder, fluid around it, dense stones, and surrounding inflammation - Ultrasound is the preferred imaging test, showing a gallbladder wall thicker than 3 mm, edema, fluid around the gallbladder, and stones - A HIDA scan can clarify the diagnosis when ultrasound or CT are inconclusive; failure of the gallbladder to fill with tracer confirms cystic duct blockage - Adding cholecystokinin during a HIDA scan can reveal acalculous cholecystitis when no stones are present, and an ejection fraction under 35% suggests biliary dyskinesia IF NOT THIS - what else fits (4) - Biliary colic, a bile duct stone, or cholangitis are the closest biliary-tract mimics - Pancreatitis, hepatitis, or gastritis can present with similar upper abdominal pain - A hiatal hernia or peptic ulcer disease should also be considered - Appendicitis, mesenteric ischemia, or a small bowel obstruction round out the differential Source StatPearls "Acute Cholecystitis" - disease-level clinical article Status traced to the source above !! MULTI-DRUG REGIMEN - all 2 drugs are given TOGETHER. Not a choice between them. !! the regimen: Ceftriaxone + Metronidazole Rx: Empiric cover on admission, gram-negatives and anaerobes | Main treatment EMPIRIC COVER ON ADMISSION, GRAM-NEGATIVES AND ANAEROBES - give all together 1. CEFTRIAXONE [1 of 2 - GIVE ALL TOGETHER] Adult 1 to 2 g intravenously or intramuscularly once daily, or the same total split into two doses. Maximum 4 g daily. - From admission until cholecystectomy - this is cover while the operation is arranged Peds 50-75 mg/kg/dose [child max 1000 mg] (Infants, children and adolescents, mild to moderate infection: 50 to 75 mg/kg per dose intramuscularly or intravenously once daily, maximum 1,000 mg per day; given once daily, that is also the per- dose ceiling above. Severe infection is dosed separately at 100 mg/kg/day divided every 12 to 24 hours. Acute cholecystitis is uncommon in childhood and usually acalculous or haemolytic in origin, and it is admitted.) 3kg -> 150-225 mg/dose 4kg -> 200-300 mg/dose 5kg -> 250-375 mg/dose 6kg -> 300-450 mg/dose 7kg -> 350-525 mg/dose 8kg -> 400-600 mg/dose 9kg -> 450-675 mg/dose 10kg -> 500-750 mg/dose 11kg -> 550-825 mg/dose 12kg -> 600-900 mg/dose 13kg -> 650-975 mg/dose 14kg -> 700-1000 mg/dose (upper capped) 15kg -> 750-1000 mg/dose (upper capped) 16kg -> 800-1000 mg/dose (upper capped) 17kg -> 850-1000 mg/dose (upper capped) 18kg -> 900-1000 mg/dose (upper capped) 19kg -> 950-1000 mg/dose (upper capped) 20kg -> 1000 mg/dose (capped) 21kg -> 1000 mg/dose (capped) 22kg -> 1000 mg/dose (capped) 23kg -> 1000 mg/dose (capped) 24kg -> 1000 mg/dose (capped) 25kg -> 1000 mg/dose (capped) 26kg -> 1000 mg/dose (capped) 27kg -> 1000 mg/dose (capped) 28kg -> 1000 mg/dose (capped) 29kg -> 1000 mg/dose (capped) 30kg -> 1000 mg/dose (capped) 31kg -> 1000 mg/dose (capped) 32kg -> 1000 mg/dose (capped) 33kg -> 1000 mg/dose (capped) 34kg -> 1000 mg/dose (capped) 35kg -> 1000 mg/dose (capped) 36kg -> 1000 mg/dose (capped) 37kg -> 1000 mg/dose (capped) 38kg -> 1000 mg/dose (capped) 39kg -> 1000 mg/dose (capped) 40kg -> 1000 mg/dose (capped) 41kg -> 1000 mg/dose (capped) 42kg -> 1000 mg/dose (capped) 43kg -> 1000 mg/dose (capped) 44kg -> 1000 mg/dose (capped) 45kg -> 1000 mg/dose (capped) 46kg -> 1000 mg/dose (capped) 47kg -> 1000 mg/dose (capped) 48kg -> 1000 mg/dose (capped) 49kg -> 1000 mg/dose (capped) 50kg -> 1000 mg/dose (capped) AWaRe WATCH group - carries resistance cost. Egyptian EML 2025. Source Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255) - general adult dosage 1 to 2 g intravenously or intramuscularly once daily or divided twice daily, maximum 4 g daily, with community-acquired intra-abdominal infection among the named indications. Why The cholecystitis article's initial management is intravenous fluid resuscitation and prompt broad-spectrum antibiotics effective against gram-negative rods and anaerobes, followed by early laparoscopic cholecystectomy during the same admission because early surgery lowers morbidity and mortality against delayed surgery. Ceftriaxone is the formulary's agent for the gram-negative half. Eight 1 g products are marketed in Egypt. Caution GIVEN WITH METRONIDAZOLE, NOT ALONE - the article asks for cover against gram-negative rods AND anaerobes. The admission comes first and this is not started in a clinic. It is here so that the referral is an informed one and so a GP recognises the regimen the patient comes back on. Right upper quadrant pain that does not settle, with fever and systemic upset and a positive Murphy's sign, is not prolonged biliary colic. Colic settles; cholecystitis does not. Contraindicated in penicillin or cephalosporin hypersensitivity, and in the neonate receiving calcium-containing intravenous fluids. Where renal and hepatic impairment coexist, the formulary caps the daily dose at 2 g. Jaundice, rigors or a septic-looking patient suggests cholangitis or a stone in the common bile duct rather than simple cholecystitis, and changes the urgency. Egypt ZOXIDEL 1 GM PD. FOR I.M. INJ. RAMEDA > DELT... 22.00 EGP CEFTRIAXONE SODIUM 1 GM I.M.VIAL (KAHIRA) KAHIRA 29.00 EGP ZOXIDEL 1 GM PD. FOR I.V. INJ. RAMEDA > DELT... 29.00 EGP WINTRIAXONE 1 GM PD. FOR I.V INJ. SANOFI 48.00 EGP VOTRIAXONE 1 GM I.M VIAL CHEMIPHARM 56.00 EGP OFRAMAX 1 GM I.M. VIAL RAMEDA > SUN ... 71.00 EGP TRIAXONE 1 GM I.M. VIAL TABUK PHARMAC... 106.00 EGP TRIAXONE 1 GM I.V VIAL TABUK PHARMAC... 106.00 EGP 2. METRONIDAZOLE [2 of 2 - GIVE ALL TOGETHER] Adult 500 mg intravenously or orally every 8 hours, as part of a combination - From admission until cholecystectomy - this is cover while the operation is arranged Peds 22.5-40 mg/kg/day [child max 4000 mg] (Infants, children and adolescents, intravenous: 22.5 to 40 mg/kg/day in 3 or 4 divided doses, maximum 4,000 mg per day. The oral band is different - 15 to 50 mg/kg/day in 3 divided doses, maximum 2,250 mg per day - so the route decides which applies; the grid above is the intravenous one.) 3kg -> 67.5-120 mg/day 4kg -> 90-160 mg/day 5kg -> 112.5-200 mg/day 6kg -> 135-240 mg/day 7kg -> 157.5-280 mg/day 8kg -> 180-320 mg/day 9kg -> 202.5-360 mg/day 10kg -> 225-400 mg/day 11kg -> 247.5-440 mg/day 12kg -> 270-480 mg/day 13kg -> 292.5-520 mg/day 14kg -> 315-560 mg/day 15kg -> 337.5-600 mg/day 16kg -> 360-640 mg/day 17kg -> 382.5-680 mg/day 18kg -> 405-720 mg/day 19kg -> 427.5-760 mg/day 20kg -> 450-800 mg/day 21kg -> 472.5-840 mg/day 22kg -> 495-880 mg/day 23kg -> 517.5-920 mg/day 24kg -> 540-960 mg/day 25kg -> 562.5-1000 mg/day 26kg -> 585-1040 mg/day 27kg -> 607.5-1080 mg/day 28kg -> 630-1120 mg/day 29kg -> 652.5-1160 mg/day 30kg -> 675-1200 mg/day 31kg -> 697.5-1240 mg/day 32kg -> 720-1280 mg/day 33kg -> 742.5-1320 mg/day 34kg -> 765-1360 mg/day 35kg -> 787.5-1400 mg/day 36kg -> 810-1440 mg/day 37kg -> 832.5-1480 mg/day 38kg -> 855-1520 mg/day 39kg -> 877.5-1560 mg/day 40kg -> 900-1600 mg/day 41kg -> 922.5-1640 mg/day 42kg -> 945-1680 mg/day 43kg -> 967.5-1720 mg/day 44kg -> 990-1760 mg/day 45kg -> 1012.5-1800 mg/day 46kg -> 1035-1840 mg/day 47kg -> 1057.5-1880 mg/day 48kg -> 1080-1920 mg/day 49kg -> 1102.5-1960 mg/day 50kg -> 1125-2000 mg/day Source Egyptian National Drug Formulary - Antimicrobial 2023 (metronidazole monograph, p306) - intra-abdominal infection, oral or intravenous 500 mg every 8 hours as part of an appropriate combination regimen, for 4 to 7 days following adequate source control. Why The article asks for anaerobic cover explicitly and names no agent. Metronidazole is the formulary's anaerobe drug, dosed there for intra-abdominal infection as part of a combination, and Egypt stocks it as a ready-to-use 500 mg in 100 mL infusion. Caution GIVEN WITH CEFTRIAXONE, NOT ALONE. It covers anaerobes only. The admission comes first; this is what the receiving team gives. No alcohol during treatment or for 3 days after, and not within 2 weeks of disulfiram. Contraindicated in active neurological disorders, blood dyscrasia, hypothyroidism and hypoadrenalism, and in the first trimester where the indication is trichomoniasis. Halve the dose in severe hepatic impairment (Child-Pugh C). How long it runs after the operation is a separate question, and the two documents differ: the article gives antibiotics afterwards only where the gallbladder was gangrenous or perforated at operation, while the formulary's intra-abdominal figure is 4 to 7 days following adequate source control. Both are recorded; the operating team decides which applies. Where surgery is not an option, the article's alternative is percutaneous drainage of the gallbladder, decided by the hospital team. Egypt METRONIDAZOLE-OTSUKA 500MG /100ML I.V. INF. 100 ML OTSUKA 20.00 EGP FLAZOL 500MG/100ML I.V.INFUSION EL NILE. 31.00 EGP AMRIZOLE 500 MG VIAL 100 ML AMRIYA 47.00 EGP METROFLAG 500MG/100ML VIAL FOR I.V. INF. ARABCOMED-EGYPT 47.00 EGP MAIN TREATMENT 3. REFERRAL & SAFETY-NETTING (NO DRUG THERAPY) [1st line] Adult Same-day hospital referral. Right upper quadrant pain with nausea, vomiting and intolerance of fatty food, plus Murphy's sign - inspiratory arrest during palpation of the right upper quadrant. This is not biliary colic that has gone on longer: colic settles, cholecystitis does not, and it is accompanied by fever and systemic upset. Ultrasound is the imaging of choice but the referral does not wait for it. - Refer, with advice Peds Rare in children and usually acalculous or associated with haemolytic disease; refer the same day. Source No dose - referral pathway, no medicine given in primary care Caution Untreated, StatPearls records gallbladder perforation as killing 30% of those it happens to. Hospital management is intravenous fluids and broad-spectrum antibiotics covering gram- negative rods and anaerobes, with laparoscopic cholecystectomy done early, on that same admission. (Acute Cholecystitis - StatPearls - NCBI Bookshelf, NBK459171) None of that is a primary-care prescription. Do not treat as biliary colic with an antispasmodic and analgesia at home once there is fever or a positive Murphy's sign. Jaundice, rigors or confusion suggest ascending cholangitis - that is an emergency admission, not a next-day referral. Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)