From the Guidelines
Diagnosis and treatment of gallbladder (cholecystitis) disease is primarily based on clinical features, imaging studies, and surgical intervention.
Diagnosis
- 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 1.
- Abdominal ultrasound is the preferred initial imaging technique for patients who are clinically suspected of having acute cholecystitis, due to its lower costs, better availability, lack of invasiveness, and good accuracy for stones 1.
- Combination of symptoms, signs, and laboratory tests results may have better diagnostic accuracy in confirming the diagnosis of acute cholecystitis 1.
Treatment
- Laparoscopic cholecystectomy is the first-line treatment for patients with acute calculus cholecystitis, and should be attempted at first, except in case of absolute anesthetic contraindications and septic shock 1.
- Early laparoscopic cholecystectomy is a safe treatment for acute cholecystitis, and generally results in shorter recovery time and hospitalization compared to delayed cholecystectomies 1.
- Antibiotic therapy may be necessary in some cases, such as complicated cholecystitis, and should be tailored to the individual patient's needs, with a duration of 4-7 days depending on the clinical conditions and inflammation indices 1.
- Cholecystostomy may be an option for acute cholecystitis in patients with multiple comorbidities and unfit for surgery patients who do not show clinical improvement after antibiotic therapy 1.
- Open cholecystectomy may be considered as an alternative to laparoscopic cholecystectomy, particularly in low-income countries or in the setting of resource limitations 1.
From the Research
Diagnosis of Gallbladder Disease
- The diagnosis of acute cholecystitis is typically made based on symptoms such as acute right upper quadrant pain, fever, and nausea, as well as physical examination findings of right upper quadrant tenderness 2.
- Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis 2.
- When an ultrasound result does not provide a definitive diagnosis, hepatobiliary scintigraphy is the gold standard diagnostic test 2.
Treatment of Gallbladder Disease
- Laparoscopic cholecystectomy is the first-line therapy for acute cholecystitis, and early performance (within 1-3 days) is associated with improved patient outcomes, including fewer composite postoperative complications and a shorter length of hospital stay 2.
- In people older than 65 years of age, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up compared with nonoperative management 2.
- A percutaneous cholecystostomy tube is an effective therapy for patients with an exceptionally high perioperative risk, but is associated with higher rates of postprocedural complications compared with laparoscopic cholecystectomy 2.
- For patients with acalculous acute cholecystitis, percutaneous cholecystostomy tube should be reserved for patients who are severely ill at the time of diagnosis; all others should undergo a laparoscopic cholecystectomy 2.
- Other treatment options, such as bile salt therapy and extracorporeal lithotripsy, have limited indications 3.
- Endoscopic retrograde cholangiopancreatography (ERCP) is mainly used to treat bile duct stones, and is indicated in certain cases prior to cholecystectomy, such as cholangitis or severe pancreatitis 3.
Special Considerations
- During pregnancy, early laparoscopic cholecystectomy is associated with a lower risk of maternal-fetal complications and is recommended during all trimesters 2.
- In special populations, such as those with calculous biliary disease, evidence-based management is crucial to ensure optimal outcomes 4.
- Red flags that warrant further intervention and/or management include severe symptoms, jaundice, and abnormal liver function tests 5.