What is the initial treatment for a patient diagnosed with cholecystitis?

From the Guidelines

The initial treatment for a patient diagnosed with cholecystitis should involve early laparoscopic cholecystectomy (ELC) within 7 days of hospital admission and within 10 days of onset of symptoms, as it is superior to delayed or intermediate laparoscopic cholecystectomy in terms of reducing hospital stay and complication rates. This approach is based on the most recent and highest quality evidence available, including the 2020 World Society of Emergency Surgery guidelines 1 and the 2024 Italian Council for the Optimization of Antimicrobial Use recommendations 1.

Initial Management

The initial management of cholecystitis includes:

• Hospital admission
• Bowel rest (NPO status)
• Intravenous fluids
• Pain management with opioid analgesics such as morphine or hydromorphone
• Antibiotic therapy to cover gram-negative organisms and anaerobes, such as piperacillin-tazobactam or a combination of ceftriaxone and metronidazole
• Supportive measures including correction of electrolyte imbalances and management of nausea with antiemetics like ondansetron

Definitive Treatment

Definitive treatment usually involves laparoscopic cholecystectomy, which is preferred over open cholecystectomy 1. The timing of laparoscopic cholecystectomy is crucial, with early laparoscopic cholecystectomy (ELC) being the recommended approach 1. ELC has been shown to reduce the total length of hospital stay and the time to return to work compared to delayed laparoscopic cholecystectomy (DLC) or intermediate laparoscopic cholecystectomy (ILC) 1.

Special Considerations

For patients who are poor surgical candidates, percutaneous cholecystostomy tube placement may be considered as a temporizing measure 1. However, it is essential to note that cholecystostomy is inferior to cholecystectomy in terms of major complications for critically ill patients 1. Antibiotic therapy should be continued for 4-7 days based on clinical conditions and inflammation indices, with a duration of up to 7 days recommended for immunocompromised or critically ill patients 1.

Key Recommendations

• Early laparoscopic cholecystectomy (ELC) within 7 days of hospital admission and within 10 days of onset of symptoms is the recommended approach for the treatment of cholecystitis 1.
• Laparoscopic cholecystectomy is preferred over open cholecystectomy 1.
• Antibiotic therapy should be continued for 4-7 days based on clinical conditions and inflammation indices 1.

From the FDA Drug Label

SURGICAL PROPHYLAXIS The preoperative administration of a single 1 gm dose of Ceftriaxone for Injection, USP may reduce the incidence of postoperative infections in patients undergoing surgical procedures classified as contaminated or potentially contaminated (e.g., vaginal or abdominal hysterectomy or cholecystectomy for chronic calculous cholecystitis in high-risk patients, such as those over 70 years of age, with acute cholecystitis not requiring therapeutic antimicrobials, obstructive jaundice or common duct bile stones)

The initial treatment for a patient diagnosed with cholecystitis is surgical intervention, and antibiotic prophylaxis with ceftriaxone may be considered to reduce the incidence of postoperative infections, especially in high-risk patients or those undergoing surgical procedures classified as contaminated or potentially contaminated 2.

From the Research

Initial Treatment for Cholecystitis

The initial treatment for a patient diagnosed with cholecystitis depends on the risk level of the patient for surgery.

• For high-risk patients, percutaneous cholecystostomy (PC) is considered an alternative to cholecystectomy 3, 4, 5, 6, 7.
• PC can be used as a definitive treatment in unfit patients or as a bridge to surgery in those who might subsequently prove fit for a definitive operation 3.
• The procedure involves the insertion of a catheter into the gallbladder to drain the infection, and it can be performed using a transperitoneal or transhepatic approach 3, 4, 6.

Effectiveness and Safety of PC

• Studies have shown that PC is a safe and effective treatment for acute cholecystitis in high-risk patients, with clinical improvement observed in the majority of patients 4, 5, 6, 7.
• The procedure has a low complication rate, and most patients can be managed with PC drainage alone or as a bridge to elective cholecystectomy 6, 7.
• However, the timing of PC insertion does not appear to affect the outcome, although delayed insertion may be associated with a higher rate of elective cholecystectomy 7.

Patient Outcomes

• Patient outcomes after PC vary, with some studies reporting a mortality rate of up to 17.9% due to severe biliary sepsis 6.
• Readmission rates for cholecystitis after PC are relatively low, ranging from 18.5% to 16.6% 6.
• Overall, PC is considered a viable alternative to cholecystectomy in high-risk patients with acute cholecystitis, providing satisfactory long-term results when cholecystectomy is not a viable option 6.