What are the key considerations in treating acute cholecystitis?

Key Considerations in Treating Acute Cholecystitis

Early laparoscopic cholecystectomy within 72 hours of diagnosis (up to 7-10 days from symptom onset) is the definitive treatment for acute cholecystitis and should be performed in all suitable patients. 1

Diagnosis and Initial Assessment

• Diagnosis is based on:

  • Clinical features: Right upper quadrant pain, fever, leukocytosis
  • Imaging: Ultrasound is first-line (sensitivity ~81%, specificity ~83%) showing:
    • Pericholecystic fluid
    • Distended gallbladder
    • Edematous gallbladder wall
    • Gallstones
    • Positive Murphy's sign 1, 2
  • If ultrasound is inconclusive, hepatobiliary scintigraphy is the gold standard 2

• Assess severity using Tokyo Guidelines classification:

  • Grade I: Mild
  • Grade II: Moderate
  • Grade III: Severe with organ dysfunction 1

Surgical Management

• Early cholecystectomy (within 72 hours) offers:

  • Shorter recovery time and hospitalization
  • Lower hospital costs
  • Fewer postoperative complications (11.8% vs 34.4% for delayed) 1, 2

• Risk factors for conversion to open cholecystectomy:

  • Age >65 years
  • Male gender
  • Thickened gallbladder wall
  • Diabetes mellitus
  • Previous upper abdominal surgery 1

Antimicrobial Therapy

Uncomplicated Acute Cholecystitis

• Class A/B patients (stable): No postoperative antibiotics needed if source control is complete 1
• Class C patients (compromised): Postoperative antibiotics required 1

Complicated Acute Cholecystitis

• Class A/B patients: Short course (1-4 days) postoperative antibiotics 1
• Class C patients: Postoperative antibiotics with duration based on clinical response 1

Empiric Antibiotic Selection

• Target common pathogens:

  • Gram-negative aerobes: E. coli, Klebsiella pneumoniae
  • Anaerobes: Bacteroides fragilis 1

• Recommended regimens based on patient stability:

  • Stable patients:
    • Amoxicillin/Clavulanate
    • Ceftriaxone + Metronidazole
    • Ciprofloxacin/Levofloxacin + Metronidazole (if beta-lactam allergy)
  • Unstable patients:
    • Piperacillin/Tazobactam
    • Cefepime + Metronidazole 1

• For healthcare-associated infections or patients from nursing homes:

  • Use broader spectrum antibiotics
  • Always obtain intraoperative cultures to guide therapy 1

Special Populations

Elderly Patients

• Laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared to non-operative management (29.3%) 2
• Consider frailty and comorbidities when deciding on surgical approach 1

Critically Ill/High-Risk Patients

• Consider percutaneous cholecystostomy as a temporizing measure or definitive therapy in patients unfit for surgery 1, 2
• Be aware that cholecystostomy has higher complication rates (65%) compared to laparoscopic cholecystectomy (12%) 2

Postoperative Care

• In patients who can tolerate oral feeding, switch from IV to oral antibiotics as soon as clinical improvement occurs 1
• For sepsis or septic shock:
  • Administer broad-spectrum IV antibiotics within the first hour
  • Reassess antimicrobial regimen daily based on patient status and pharmacokinetics 1

Common Pitfalls to Avoid

1. Delayed surgery: Avoid postponing cholecystectomy beyond 72 hours when possible, as this increases complications and hospital stay 1, 2

2. Unnecessary postoperative antibiotics: In uncomplicated cases with successful source control, postoperative antibiotics are not needed 1

3. Inadequate empiric coverage: For healthcare-associated infections or critically ill patients, ensure broad-spectrum coverage until culture results are available 1

4. Failure to obtain cultures: Always send bile samples for culture to guide targeted antibiotic therapy 1, 3

5. Overlooking sepsis: In patients with sepsis, early administration of appropriate antibiotics significantly impacts outcomes 1