What is the treatment for acute cholecystitis?

Treatment of Acute Cholecystitis

Early laparoscopic cholecystectomy is the treatment of choice for acute cholecystitis, ideally performed within 7-10 days of symptom onset, with appropriate antibiotic therapy based on disease severity. 1

Initial Assessment and Management

Diagnosis

• Ultrasonography is the first-line imaging technique
• Key findings: gallbladder wall thickening, pericholecystic fluid, distended gallbladder, positive sonographic Murphy's sign 1

Initial Medical Management

• Fasting
• Intravenous fluid resuscitation
• Pain management
  • NSAIDs as first-line therapy
  • Acetaminophen as alternative or adjunct
  • Oral opioids for breakthrough pain 1
• Low-fat diet during acute phase with small, frequent meals when oral intake is resumed 1

Definitive Treatment

Surgical Management

1. Early Laparoscopic Cholecystectomy

   • Preferred treatment for both uncomplicated and complicated cholecystitis
   • Timing: As soon as patient is stabilized, ideally within 7-10 days of symptom onset 2, 1
   • Benefits: Lower complication rates, shorter hospital stays, reduced mortality

2. Interval Cholecystectomy

   • When early surgery is not feasible
   • Schedule after 6-12 weeks from symptom onset to allow inflammation to resolve 1

3. Percutaneous Cholecystostomy

   • Indicated for:
     • Critically ill patients with multiple comorbidities
     • Patients unfit for surgery
     • Patients not improving after 3-5 days of antibiotic therapy 2, 1
   • Note: Generally inferior to cholecystectomy for critically ill patients; consider only when surgery is contraindicated 1

Antibiotic Therapy

Uncomplicated Acute Cholecystitis

• Class A or B patients with successful cholecystectomy:
  • No postoperative antibiotics needed if source control is adequate 2, 1
  • Preoperative antibiotics should be administered 1

Complicated Acute Cholecystitis

• Class A or B patients:

  • Cholecystectomy as urgent procedure
  • Short course postoperative antibiotic therapy (1-4 days) 2

• Class C patients:

  • Emergent cholecystectomy with postoperative antibiotic therapy
  • Duration based on clinical improvement 2

Empiric Antibiotic Options

• Mild to moderate cases:

  • Amoxicillin/Clavulanate 875mg/125mg orally every 12 hours
  • Ciprofloxacin 500 mg every 12 hours plus Metronidazole 500 mg every 8 hours 1

• Severe or critically ill patients:

  • Piperacillin/tazobactam 6g/0.75g loading dose then 4g/0.5g q6h or 16g/2g by continuous infusion
  • Eravacycline 1 mg/kg every 12 hours
  • Tigecycline 100 mg loading dose then 50 mg every 12 hours 1

Duration of Therapy

• Uncomplicated cholecystitis: 4 days total
• Complicated cholecystitis or immunocompromised patients: up to 7 days total 1

Special Considerations

Elderly Patients

• Higher risk for complications
• May require more cautious antibiotic management due to:
  • Changes in pharmacokinetics and pharmacodynamics
  • Potential drug interactions
  • Renal effects of coexisting diseases 2

Patients with Multidrug-Resistant Organisms

• Consider antibiotic resistance in patients from healthcare facilities or nursing homes
• Obtain intraoperative cultures to guide antibiotic therapy 1

Monitoring and Follow-up

• Monitor for signs of ongoing infection:
  • Fever
  • Worsening abdominal pain
  • Purulent drainage from surgical sites
  • Increasing white blood cell count 1
• Discontinue antibiotics when:
  • Patient is afebrile for 24 hours
  • White blood cell count normalizes
  • No signs of ongoing infection 1

Pitfalls to Avoid

• Delaying surgical intervention beyond 10 days from symptom onset
• Continuing broad-spectrum antibiotics unnecessarily after source control
• Overlooking complications such as gangrenous, hemorrhagic, or emphysematous cholecystitis
• Failing to adjust antibiotic therapy based on culture results when available
• Underestimating the need for multidisciplinary management in critically ill patients 2, 1