What is the treatment for acute cholecystitis?

From the Guidelines

Acute cholecystitis treatment requires prompt intervention with antibiotics, pain management, and definitive surgical management, with laparoscopic cholecystectomy being the preferred treatment, even in elderly patients, as it is safe, feasible, and associated with shortened hospital stay 1. The initial treatment includes IV antibiotics such as piperacillin-tazobactam 3.375g every 6 hours, or a combination of ceftriaxone 1-2g daily plus metronidazole 500mg every 8 hours to cover enteric gram-negative bacteria and anaerobes. Pain should be managed with NSAIDs like ketorolac 30mg IV or opioids such as morphine 2-4mg IV as needed. Patients should remain NPO (nothing by mouth) and receive IV fluids. The definitive treatment is cholecystectomy, preferably laparoscopic, which should be performed within 24-72 hours of diagnosis in most cases, as early surgery reduces overall hospital stay and complications compared to delayed intervention 1. Some key points to consider in the treatment of acute cholecystitis include:

• The evaluation of the risk for elderly patients with acute cholecystitis should include mortality rate for conservative and surgical therapeutic options, rate of gallstone-related disease relapse and the time to relapse, age-related life expectancy, and consideration of patient frailty evaluation by the use of frailty scores 1.
• In elderly patients with acute cholecystitis, laparoscopic approach should always be attempted at first, except in case of absolute anesthetic contraindications and septic shock 1.
• Percutaneous cholecystostomy can be considered in the treatment of acute cholecystitis patients who are deemed unfit for surgery, as a bridge to cholecystectomy in acutely ill (high-risk) elderly patients deemed unfit for surgery, in order to convert them into a moderate risk patient, more suitable for surgery 1. For patients who are poor surgical candidates due to severe comorbidities, percutaneous cholecystostomy tube placement may be considered as a temporizing measure. Following cholecystectomy, most patients can be discharged within 24 hours if the procedure was uncomplicated, with oral antibiotics only necessary if perforation or significant contamination occurred during surgery. This approach effectively treats the infection, removes the source of inflammation, and prevents recurrence of symptoms. It is also important to note that immediate laparoscopic cholecystectomy is superior to percutaneous transhepatic gallbladder drainage (PTGBD) in high-risk patients with acute cholecystitis, and should be considered as the first-choice treatment in this group of patients 1.

From the Research

Treatment Overview

• Acute cholecystitis is typically treated with early laparoscopic cholecystectomy, which is associated with improved patient outcomes, including fewer composite postoperative complications and a shorter length of hospital stay 2.
• The optimal timeframe to perform early laparoscopic cholecystectomy is within 72 hours from diagnosis, with a possible extension of up to 7-10 days from symptom onset 3.

Antibiotic Therapy

• Antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis 4.
• 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 4.
• The Surgical Infection Society recommends the use of peri-operative antibiotic agents for patients undergoing laparoscopic cholecystectomy for acute cholecystitis, but against routine use in low-risk patients undergoing elective laparoscopic cholecystectomy 5.

Alternative Treatments

• Percutaneous cholecystostomy or endoscopic procedures are alternative treatments in selective cases, such as patients who are not eligible for early laparoscopic cholecystectomy or those with high perioperative risk 3, 2.
• A percutaneous cholecystostomy tube can be an effective therapy for patients with exceptionally high perioperative risk, but it is associated with higher rates of postprocedural complications compared to laparoscopic cholecystectomy 2.

Special Populations

• In pregnant women, early laparoscopic cholecystectomy is recommended during all trimesters, as it is associated with a lower risk of maternal-fetal complications compared to delayed operative management 2.
• In people older than 65 years of age, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up compared to nonoperative management 2.