What is the initial management of acute cholecystitis?

Initial Management of Acute Cholecystitis

Early laparoscopic cholecystectomy within 24-72 hours of diagnosis is the definitive first-line treatment for acute cholecystitis in patients fit for surgery. 1

Diagnostic Approach

• First-line imaging: Abdominal ultrasonography with key findings including:

  • Gallbladder wall thickening
  • Pericholecystic fluid
  • Distended gallbladder
  • Positive sonographic Murphy's sign 1

• If ultrasound is inconclusive, hepatobiliary iminodiacetic acid (HIDA) scan is the gold standard diagnostic test 2

• CT scan is preferred for suspected complications such as:

  • Gallbladder perforation (look for "hole sign", free fluid, extraluminal gallstones)
  • Emphysematous cholecystitis (gas in gallbladder lumen/wall) 1

Initial Medical Management

1. Fluid resuscitation: Intravenous hydration 3
2. Bowel rest: NPO (nothing by mouth) 3
3. Antibiotic therapy:
   • For mild-moderate community-acquired cases:
     • First-line: Cefazolin (2g IV) or Cefuroxime (1.5g IV)
     • Add vancomycin for MRSA risk 1
   • For severe or healthcare-associated cases:
     • Broader coverage with piperacillin-tazobactam, carbapenems, or cefepime plus metronidazole 1
   • Obtain cultures in complicated cases or patients at high risk for antimicrobial resistance 1
4. Pain management:
   • Oral NSAIDs as first-line therapy
   • Acetaminophen as alternative or adjunct 1

Surgical Management

Patient Classification and Treatment Approach

1. Low-risk surgical candidates:

   • Early laparoscopic cholecystectomy (within 24-72 hours of diagnosis)
   • No postoperative antibiotics needed for uncomplicated cases 1

2. High-risk surgical candidates:

   • Percutaneous cholecystostomy as a bridge to surgery
   • Preferred transhepatic approach to minimize bile leakage
   • Consider for elderly patients, those with septic shock, diabetes mellitus 1

3. Emergency intervention required:

   • Immediate surgical intervention for gallbladder perforation
   • Even if patient already has a percutaneous cholecystostomy tube 1

Special Considerations

• Elderly patients: Can be treated without postoperative antibiotics when infection source is controlled by cholecystectomy 1

• Complicated cholecystitis: Requires urgent or emergent cholecystectomy with postoperative antibiotics 1

• Post-percutaneous cholecystostomy: Elective cholecystectomy typically performed after 3 months once patient has stabilized 1

Complications to Monitor

• Perforation of gallbladder (2-11% of cases) has 12-16% mortality rate 1
• Acalculous cholecystitis has higher 30-day mortality (45.2%) compared to calculous cholecystitis (21.2%) 1
• Post-cholecystectomy complications include infection, bleeding, or bile duct injury 1

Important Clinical Caveat

Acute cholecystitis may present atypically without classic findings such as leukocytosis, fever, or positive Murphy's sign. Maintain high clinical suspicion and pursue appropriate imaging when symptoms suggest biliary pathology, even with normal laboratory values 3.