What is the initial management for inpatient treatment of acute cholecystitis?

Inpatient Management of Acute Cholecystitis

Early laparoscopic cholecystectomy within 7-10 days of symptom onset is the definitive treatment for acute cholecystitis, combined with appropriate antimicrobial therapy based on severity. 1

Initial Assessment and Diagnosis

Clinical Presentation

• Right upper quadrant abdominal pain
• Murphy's sign (pain on palpation during inspiration)
• Fever
• Abdominal tenderness
• Palpable gallbladder lump (indicates complicated cholecystitis)

Diagnostic Imaging

• Ultrasound is the investigation of choice for suspected acute cholecystitis 1

• Findings include:

  • Pericholecystic fluid
  • Distended gallbladder with edematous wall
  • Gallstones (often impacted in cystic duct)
  • Positive sonographic Murphy's sign

• Alternative imaging:

  • CT with IV contrast if ultrasound is inconclusive
  • MRCP if common bile duct stones are suspected 1

Initial Management Algorithm

1. Supportive Care

• NPO (nothing by mouth)
• Intravenous fluid resuscitation
• Pain management
• Correction of electrolyte imbalances

2. Antimicrobial Therapy

Therapy should be guided by severity of cholecystitis:

Uncomplicated Cholecystitis in Non-Critically Ill, Immunocompetent 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

Complicated Cholecystitis or Critically Ill/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

Patients with Septic Shock:

• Meropenem 1g q6h by extended or continuous infusion 1

3. Definitive Treatment

Uncomplicated Cholecystitis:

• Early laparoscopic cholecystectomy within 7-10 days of symptom onset 1
• One-shot antibiotic prophylaxis if early intervention
• No post-operative antibiotics needed if source control is adequate 1

Complicated Cholecystitis:

• Laparoscopic cholecystectomy (open cholecystectomy as alternative)
• Continue antibiotics for 4 days in immunocompetent patients if source control is adequate
• Continue antibiotics up to 7 days in immunocompromised or critically ill patients 1

Patients Unfit for Surgery:

• Cholecystostomy (percutaneous gallbladder drainage) for patients with multiple comorbidities who do not improve with antibiotic therapy 1
• Note: Cholecystostomy is inferior to cholecystectomy in terms of major complications for critically ill patients 1

Duration of Antimicrobial Therapy

• Uncomplicated cholecystitis with early surgery: One-shot prophylaxis only, no post-operative antibiotics 1
• Uncomplicated cholecystitis with delayed surgery: Antibiotics for no more than 7 days 1
• Complicated cholecystitis with adequate source control:
  • Immunocompetent patients: 4 days 1
  • Immunocompromised/critically ill: Up to 7 days based on clinical condition and inflammatory markers 1

Special Considerations

Microbiological Sampling

• Obtain intraoperative bile cultures to guide targeted antibiotic therapy, especially in healthcare-associated infections 1
• Common pathogens include E. coli, Klebsiella pneumoniae, and anaerobes (especially Bacteroides fragilis) 1, 2

Monitoring Response

• Patients who have ongoing signs of infection beyond 7 days of antibiotic treatment warrant further diagnostic investigation 1
• Adjust antibiotics based on culture results to narrower spectrum agents when available 2

Choledocholithiasis

• If common bile duct stones are suspected, perform MRCP 1
• ERCP is the treatment of choice for biliary decompression in moderate/severe acute cholangitis 1

Pitfalls and Caveats

1. Delayed surgery risks: Conservative treatment alone has higher rates of complications, mortality, and longer hospitalization compared to early surgical intervention 3

2. Antibiotic selection: Avoid prolonged aminoglycoside therapy in cholestasis due to increased risk of nephrotoxicity 4

3. Elderly patients: Often have atypical presentations and higher risk of complications. Early cholecystectomy remains the preferred approach when feasible 1

4. Recurrence risk: Delaying cholecystectomy increases the risk of recurrent biliary events and complications 5

5. Inadequate source control: Failure to achieve adequate biliary drainage is the most important factor in predicting septicemia 4