• Antibiotic therapy providing Gram negative and anaerobic cover (e.g. 2nd or 3rd generation cephalosporin, quinolone or carbapenem, plus metronidazole ± aminoglycoside). Treatment can be amended depending on culture results and patient response.

• Ultrasonic or CT-guided drainage of pus.

• Laparotomy with removal of pus, peritoneal lavage, etc.

A negative laparotomy should be viewed as a useful means of excluding intra-abdominal sepsis rather than an unnecessary procedure. Laparotomy should be encouraged if the patient deteriorates and a high suspicion of abdominal pathology persists.

Cholecystitis, with or without (acalculous) gallstones, may present with signs of infection. There is a characteristic ultrasound appearance of an enlarged organ with a thickened, oedematous wall surrounded by fluid. Treatment is often conservative with antibiotics (as above) and percutaneous, ultrasound-guided drainage via a pigtail catheter. Cholecystectomy is rarely necessary in the acute situation unless the gall bladder has perforated, though some authorities argue that this is the treatment of choice for acalculous cholecystitis.

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