From the Guidelines
The recommended treatment for acute cholecystitis is early laparoscopic cholecystectomy, which should be performed within 7-10 days of symptom onset, as it reduces overall hospital stay and complication rates compared to delayed intervention 1.
Initial Management
Initial treatment includes:
- Bowel rest (NPO status)
- Intravenous fluids for hydration
- Pain control with medications like morphine or hydromorphone
- Broad-spectrum antibiotics such as piperacillin-tazobactam (3.375g IV every 6 hours), ceftriaxone (1-2g IV daily) plus metronidazole (500mg IV every 8 hours), or ciprofloxacin (400mg IV every 12 hours) plus metronidazole
Definitive Treatment
Definitive treatment is cholecystectomy, preferably laparoscopic, which is safe and effective for acute cholecystitis 1.
- Early laparoscopic cholecystectomy is recommended for patients with acute cholecystitis, as it reduces the risk of complications and shortens hospital stay 1.
- For patients who are poor surgical candidates due to severe comorbidities, percutaneous cholecystostomy tube placement may be considered as a temporizing measure 1.
Special Considerations
- In elderly patients, laparoscopic cholecystectomy is safe and feasible, with a low complication rate, and is associated with shortened hospital stay 1.
- In patients with complicated acute cholecystitis, cholecystectomy should be performed as an urgent procedure, with short-course postoperative antibiotic therapy (1-4 days) 1.
- Cholecystostomy may be an option for acute cholecystitis in patients with multiple comorbidities and unfit for surgery, or in patients who do not show clinical improvement after antibiotic therapy for 3-5 days 1.
From the Research
Treatment Overview
The recommended treatment for acute cholecystitis involves a combination of medical management and surgical intervention.
- Early laparoscopic cholecystectomy (ELC) is considered the best treatment for acute cholecystitis, with the optimal timeframe for performing ELC being within 72 hours from diagnosis 2.
- Medical management includes fasting, intravenous fluid infusion, antimicrobial therapy, and possible administration of analgesics 2.
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.
- Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment 3.
- The choice of antibiotic must be made considering factors such as the severity of clinical manifestations, the onset of infection, and drug resistance 3.
- Antibiotic stewardship is crucial, and the appropriate use of antibiotic agents should be integrated into good clinical practice and standards of care 3, 4.
Special Considerations
Certain patient populations require special consideration when managing acute cholecystitis.
- In patients who are not eligible for ELC, surgery may be delayed at least 6 weeks after clinical presentation 2.
- Critically ill patients may require rescue treatments such as percutaneous or endoscopic gallbladder drainage (GBD) 2, 5.
- Pregnant women, cirrhotic patients, and elderly patients may require a particular treatment approach 2.
- In some cases, gallstone removal using the percutaneous tract or endoscopy may be considered as an alternative to cholecystectomy 5.
Surgical Intervention
Surgical intervention is a crucial component of acute cholecystitis management.
- Early laparoscopic cholecystectomy is recommended for patients undergoing cholecystectomy for acute cholecystitis 4.
- Peri-operative antibiotic agents are recommended for patients undergoing laparoscopic cholecystectomy for acute cholecystitis 4.
- Post-operative antibiotic agents are not recommended after elective laparoscopic cholecystectomy for symptomatic cholelithiasis or mild to moderate acute cholecystitis 4.