Treatment of Acute Cholecystitis
Early laparoscopic cholecystectomy (within 72 hours of diagnosis or 7-10 days from symptom onset) is the definitive treatment for acute cholecystitis and should be performed in most patients to reduce complications, hospital stay, and costs. 1, 2
Diagnosis
Clinical Presentation
- Right upper quadrant abdominal pain
- Murphy's sign (pain on palpation during inspiration)
- Fever
- Nausea/vomiting
- Abdominal tenderness
- Palpable gallbladder lump (sign of complicated cholecystitis)
Diagnostic Imaging
- Ultrasound (first-line investigation): Look for gallstones, gallbladder wall thickening (≥5mm), pericholecystic fluid, and ultrasonographic Murphy's sign 1
- CT with IV contrast (if ultrasound is inconclusive)
- MRCP (if common bile duct stones are suspected)
- Hepatobiliary scintigraphy (gold standard if ultrasound is inconclusive) 3
Treatment Algorithm
1. Uncomplicated Cholecystitis
Early Treatment (Preferred)
- Early laparoscopic cholecystectomy within 72 hours of diagnosis or 7-10 days from symptom onset 1, 2
- One-shot antibiotic prophylaxis for surgery
- No post-operative antibiotics required
Initial Management (Pre-operative)
- NPO (nothing by mouth)
- Intravenous fluid resuscitation
- Pain management
- Consider antibiotic therapy
2. Complicated Cholecystitis
- Laparoscopic cholecystectomy (open cholecystectomy as alternative)
- Antibiotic therapy for 4 days in immunocompetent, non-critically ill patients 1
- Extended antibiotic therapy up to 7 days in immunocompromised or critically ill patients 1
3. High Surgical Risk Patients
For patients unfit for surgery due to multiple comorbidities or critical illness:
- Percutaneous cholecystostomy as a temporizing or definitive procedure 1, 4
- Appropriate antibiotic therapy
- Consider interval cholecystectomy if patient's condition improves
Antibiotic Therapy
Immunocompetent, Non-Critically Ill Patients
- Amoxicillin/Clavulanate 2g/0.2g q8h 1
- For beta-lactam allergy: Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose then 50 mg q12h 1
Critically Ill or Immunocompromised Patients
- Piperacillin/Tazobactam 6g/0.75g loading dose then 4g/0.5g q6h or 16g/2g by continuous infusion 1
- For beta-lactam allergy: Eravacycline 1 mg/kg q12h 1
High Risk for ESBL-producing Enterobacterales
- Ertapenem 1g q24h or Eravacycline 1 mg/kg q12h 1
Septic Shock
- Meropenem 1g q6h by extended infusion or continuous infusion, or
- Doripenem 500mg q8h by extended infusion or continuous infusion, or
- Imipenem/cilastatin 500mg q6h by extended infusion, or
- Eravacycline 1 mg/kg q12h 1
Special Considerations
Elderly Patients
- Age alone is not a contraindication for surgery 1
- Laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared to non-operative management (29.3%) 3
- Consider frailty and comorbidities rather than age alone when deciding treatment approach
Duration of Antibiotic Therapy
- Uncomplicated cholecystitis with early surgery: one-shot prophylaxis only 1
- Complicated cholecystitis: 4 days for immunocompetent patients, up to 7 days for immunocompromised or critically ill patients 1
- Investigate further if infection signs persist beyond 7 days of antibiotic treatment 1
Important Caveats
Timing matters: Early cholecystectomy (within 72 hours) is associated with fewer complications, shorter hospital stays, and lower costs compared to delayed surgery 3
Percutaneous cholecystostomy limitations: While effective as a rescue treatment for critically ill patients, it has higher rates of postprocedural complications (65%) compared to laparoscopic cholecystectomy (12%) 3
Antibiotics alone may not be sufficient: In mild acute calculous cholecystitis, intravenous antibiotics alone do not significantly improve outcomes compared to supportive care only 5
Microbiological sampling: Intraoperative cultures should be performed in healthcare-associated infections to guide targeted antibiotic therapy 1
Cholecystostomy considerations: May be inferior to cholecystectomy for critically ill patients but remains an option when surgery is contraindicated 1, 4