From the Guidelines
Cholecystitis should be treated with early laparoscopic cholecystectomy (ELC) within 7 days of hospital admission and within 10 days of onset of symptoms, as it is a safe and effective treatment that results in shorter recovery time and hospitalization compared to delayed cholecystectomies. This approach is supported by the most recent and highest quality study, which reported that ELC is superior to delayed laparoscopic cholecystectomy (DLC) in terms of reducing hospital stay and improving patient outcomes 1.
Key Considerations
- The diagnosis of acute cholecystitis is made on the basis of clinical features such as right upper quadrant pain, fever, and leukocytosis, and is supported by findings from relevant imaging studies, with ultrasound being the investigation of choice 1.
- For patients who cannot undergo surgery, percutaneous cholecystostomy tube placement may be considered, especially in critically ill patients with multiple comorbidities and unfit for surgery 1.
- Antibiotic therapy should be tailored based on the severity of the disease and the patient's condition, with empiric regimens including ceftriaxone and metronidazole or piperacillin-tazobactam, and should be continued for 4-7 days depending on clinical response 1.
Treatment Approach
- Early laparoscopic cholecystectomy (ELC) is the recommended treatment for acute cholecystitis, as it provides immediate and definitive surgical treatment, resulting in shorter recovery time and hospitalization compared to delayed cholecystectomies 1.
- Percutaneous cholecystostomy may be an option for patients who are unfit for surgery or have multiple comorbidities, and can be considered as a bridge to surgery or as a definitive treatment in selected cases 1.
- Antibiotic therapy should be used in conjunction with surgical treatment, and should be tailored based on the severity of the disease and the patient's condition, with empiric regimens including ceftriaxone and metronidazole or piperacillin-tazobactam 1.
Prevention and Management
- Prevention involves maintaining a healthy weight, eating regular meals, and following a low-fat diet.
- Prompt treatment is essential to prevent complications like perforation, gangrene, or sepsis.
- The inflammation occurs when bile becomes trapped, causing gallbladder distension, increased pressure, and potential bacterial infection, most commonly with E. coli, Klebsiella, or Enterococcus species.
From the Research
Definition and Treatment of Cholecystitis
- Cholecystitis is a relatively frequent disease that can lead to serious complications, generally associated with the presence of gallstones 2.
- The optimal treatment for acute cholecystitis (AC) is early laparoscopic cholecystectomy (ELC), which should be performed within 72 hours from diagnosis, with a possible extension of up to 7-10 days from symptom onset 2.
Antibiotic Use in Cholecystitis
- The use of antibiotic agents in patients undergoing cholecystectomy for gallbladder disease is recommended for patients with acute cholecystitis, but not for low-risk patients undergoing elective laparoscopic cholecystectomy 3.
- In patients with moderate acute cholecystitis, narrow-spectrum antibiotics have comparable clinical outcomes to broad-spectrum antibiotics after percutaneous cholecystostomy 4.
- However, in severe acute cholecystitis, broad-spectrum antibiotics may still be necessary to rescue these patients 4.
- A systematic review found that antibiotics are not indicated for the conservative management of acute calculous cholecystitis or in patients scheduled for cholecystectomy 5.
Updates on Antibiotic Regimens
- Antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis 6.
- The choice of antibiotic must be made considering factors such as the severity of the clinical manifestations, the onset of the infection, and any drug resistance 6.
- Therapy must be modified based on bile cultures in cases of severe cholecystitis, and antibiotic stewardship is the key to the correct management of bile-related infections 6.