From the Guidelines
Cholecystitis is an inflammation of the gallbladder that requires prompt medical attention, and the primary treatment for acute cholecystitis is typically laparoscopic cholecystectomy (surgical removal of the gallbladder) as recommended by the most recent guidelines 1. 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 in patients suspected of having acute cholecystitis 1. Initial management includes:
- Fasting (NPO - nothing by mouth)
- Intravenous fluids for hydration
- Pain control with medications like morphine or hydromorphone
- Antibiotic therapy, such as:
- Piperacillin-tazobactam 3.375g IV every 6 hours, or
- Ceftriaxone 1g IV daily plus metronidazole 500mg IV every 8 hours Surgery is usually performed within 24-72 hours of admission, depending on the severity and duration of symptoms, with early cholecystectomy being a safe treatment for acute cholecystitis and generally resulting in shorter recovery time and hospitalization compared to delayed cholecystectomies 1. For patients with uncomplicated cholecystitis who are stable, outpatient management with oral antibiotics (e.g., amoxicillin-clavulanate 875/125mg twice daily for 7-10 days) and follow-up for elective cholecystectomy may be appropriate, with the goal of preventing complications such as gangrene, perforation, or sepsis 1. The most recent guidelines recommend that cholecystectomy should be performed as an urgent procedure with short course postoperative antibiotic therapy (1–4 days) for Class A or B patients with complicated acute cholecystitis, and as an emergent procedure with postoperative antibiotic therapy for Class C patients fit for surgery with complicated acute cholecystitis 1.
From the Research
Definition and Causes of Cholecystitis
- Cholecystitis is a common serious complication of gallstones, with approximately 90% to 95% of cases being gallstone-associated 2.
- It is an inflammation of the gallbladder, which can lead to serious complications if left untreated or if treatment is delayed 3, 4.
- Acalculous cholecystitis, which accounts for 5% to 10% of cases, is defined as acute inflammation of the gallbladder without gallstones, typically occurring in critically ill patients 2.
Symptoms and Diagnosis
- Typical symptoms of acute cholecystitis include acute right upper quadrant pain, fever, and nausea, which may be associated with eating 2.
- Ultrasonography is often used to confirm the clinical diagnosis, with a sensitivity of approximately 81% and a specificity of approximately 83% 2.
- Hepatobiliary scintigraphy is considered the gold standard diagnostic test when an ultrasound result is inconclusive 2.
Treatment and Management
- Early laparoscopic cholecystectomy (within 1-3 days of diagnosis) is the recommended treatment for acute cholecystitis, with improved patient outcomes and lower hospital costs 2, 5.
- Percutaneous cholecystostomy tube placement is an effective therapy for patients with high perioperative risk, but is associated with higher rates of postprocedural complications compared to laparoscopic cholecystectomy 2, 6.
- In critically ill patients, cholecystostomy tubes should remain in place until the patient is deemed medically suitable to undergo cholecystectomy, as removal of the tube without subsequent cholecystectomy is associated with a high incidence of recurrent cholecystitis 6.