What is the treatment for acute cholecystitis?

Treatment of Acute Cholecystitis

Early laparoscopic cholecystectomy is the definitive treatment of choice for acute cholecystitis and should be performed within 72 hours of diagnosis for optimal outcomes. 1, 2

Initial Management

1. Hospital Admission and Stabilization

   • Intravenous hydration
   • Nothing by mouth (NPO)
   • Pain management (oral NSAIDs as first-line therapy) 2
   • Nasogastric tube if ileus is present 3

2. Antibiotic Therapy

   • Recommended for patients with acute cholecystitis undergoing laparoscopic cholecystectomy 4
   • First-line options: Ticarcillin/Clavulanate, Ceftriaxone + Metronidazole, or Piperacillin/Tazobactam 2
   • For uncomplicated cases: discontinue after cholecystectomy 2
   • For complicated cases: broader spectrum antibiotics (Piperacillin/Tazobactam, Cefepime + Metronidazole, or Ertapenem) 2
   • Duration: 3-5 days for non-critical, immunocompetent patients 2
   • Always obtain intraoperative bile cultures to guide targeted therapy 2

Surgical Management

Early Laparoscopic Cholecystectomy

• Optimal timing: within 72 hours of diagnosis, can be extended up to 7-10 days from symptom onset 1, 2, 5
• Benefits: shorter hospital stays, fewer complications, lower mortality rates, and quicker return to productivity 1, 2, 3
• Standard approach: conventional 3-4 port laparoscopic cholecystectomy 6

Risk Factors for Conversion to Open Procedure

• Age >65 years
• Male gender
• Thickened gallbladder wall
• Diabetes mellitus
• Previous upper abdominal surgery 1, 2

Post-Operative Care

• For uncomplicated cases: no post-operative antibiotics needed 4
• For mild/moderate acute cholecystitis: post-operative antibiotics not recommended 4
• For severe (Tokyo Guidelines grade III) cholecystitis: maximum 4 days of antibiotics 4

Alternative Management for High-Risk Patients

Cholecystostomy/Gallbladder Drainage

• Indicated for critically ill patients with multiple comorbidities or those unfit for surgery 1, 2
• Options include:
  1. Percutaneous transhepatic gallbladder drainage (PTGBD)
  2. Endoscopic transpapillary gallbladder drainage (ETGBD)
  3. Ultrasound-guided transmural gallbladder drainage (EUS-GBD) 2

Delayed/Interval Cholecystectomy

• If early cholecystectomy not feasible, schedule interval cholecystectomy after 6-12 weeks from symptom onset 2, 5
• Allows acute inflammation to resolve, making surgery technically easier 2
• Note: Delayed approach carries risk of recurrent symptoms and complications during waiting period 5

Special Considerations

Gallbladder Perforation

• Requires immediate surgical intervention
• Associated with high morbidity and mortality (12-16%) if not promptly treated 1

Elderly Patients

• Early laparoscopic cholecystectomy still recommended when feasible
• May require broader spectrum antibiotics, especially for patients from institutions (risk of multidrug-resistant organisms) 2

Monitoring and Follow-up

• Monitor for clinical improvement: decreasing fever, abdominal pain, normalizing white blood cell count 2
• Watch for signs of ongoing infection or complications such as gangrenous, hemorrhagic, or emphysematous cholecystitis 2
• Discontinue antibiotics if patient is afebrile for 24 hours, white blood cell count normalizes, and there are no signs of ongoing infection 2

Complications to Watch For

• Bile duct injuries (more common with laparoscopic approach)
• Gangrenous cholecystitis
• Emphysematous cholecystitis
• Gallbladder perforation 1, 2, 6