Management of Acute Cholecystitis
Early laparoscopic cholecystectomy (within 7 days of hospital admission and within 10 days of symptom onset) is the definitive treatment of choice for acute cholecystitis, resulting in shorter recovery time and hospitalization compared to delayed approaches. 1, 2
Diagnosis
Clinical Presentation
- Right upper quadrant pain and tenderness
- Fever
- Nausea/vomiting
- Murphy's sign (pain on palpation during inspiration)
- Leukocytosis
Imaging
- Ultrasound - first-line imaging modality with highest diagnostic yield 2, 1
- Characteristic findings: pericholecystic fluid, distended gallbladder, edematous gallbladder wall (≥5mm), gallstones, sonographic Murphy's sign
- Alternative imaging:
Management Algorithm
1. Initial Management
- NPO (nothing by mouth)
- Intravenous fluid resuscitation
- Pain management
- Antimicrobial therapy based on severity:
Uncomplicated Cholecystitis (non-critically ill, immunocompetent)
- Amoxicillin/Clavulanate 2g/0.2g q8h 2
- For beta-lactam allergy:
Complicated Cholecystitis (critically ill or immunocompromised)
- Piperacillin/tazobactam 6g/0.75g loading dose then 4g/0.5g q6h or 16g/2g by continuous infusion 2
- For beta-lactam allergy:
- Eravacycline 1 mg/kg q12h 2
- For septic shock:
- Consider carbapenems (meropenem 1g q6h by extended infusion) 2
2. Definitive Management
Early Laparoscopic Cholecystectomy
- Perform within 7 days of admission and within 10 days of symptom onset 2, 1
- Benefits: shorter hospital stay, fewer work days lost, greater patient satisfaction 2
- One-shot antibiotic prophylaxis if early intervention 2, 1
- No post-operative antibiotics needed if source control is complete 2
Delayed Cholecystectomy
- If early cholecystectomy cannot be performed, delay at least 6 weeks from clinical presentation 1, 3
- Continue antibiotics for 4-7 days based on patient condition 2
Percutaneous Cholecystostomy
- Reserved for patients unfit for surgery due to critical illness or multiple comorbidities 2, 4
- Note: Inferior to cholecystectomy in terms of major complications 2
- Consider in patients who do not improve after antibiotic therapy 2
Special Considerations
Duration of Antibiotic Therapy
- Uncomplicated cholecystitis with adequate source control: 4 days 2
- Complicated cholecystitis or immunocompromised patients: up to 7 days 2
- Patients with ongoing signs of infection beyond 7 days warrant further investigation 2
Risk Factors for Conversion to Open Cholecystectomy
- Age >65 years
- Male gender
- Thickened gallbladder wall
- Diabetes mellitus
- Previous upper abdominal surgery 2, 1
Pitfalls and Caveats
Delay in diagnosis and treatment: Elderly patients may present with deceptively benign clinical presentations, leading to delayed diagnosis. Prompt recognition and surgical intervention are crucial to prevent complications 5.
Antibiotic resistance: In patients from healthcare facilities or nursing homes, consider the risk of multidrug-resistant organisms. Obtain intraoperative cultures to guide antibiotic therapy 2.
Overreliance on conservative management: Conservative management alone is unlikely to be successful in elderly patients with acute cholecystitis. Optimal management consists of resuscitation and prompt operation 5.
Inadequate source control: Ensure complete source control during surgery, as this determines the need for and duration of postoperative antibiotics 2.
Failure to recognize complications: Be vigilant for complications such as gangrenous cholecystitis, empyema, perforation, or biliary sepsis, which require more aggressive management 2, 5.