What is the initial approach to managing acute cholecystitis?

Initial Management of Acute Cholecystitis

Early laparoscopic cholecystectomy within 24-72 hours of diagnosis is the definitive treatment of choice for uncomplicated acute cholecystitis. 1

Immediate Management Steps

1. Initial Medical Management

   • Fluid resuscitation: Goal-directed fluid therapy 2
   • NPO status: Keep patient nil per os initially 1
   • Pain control: NSAIDs as first-line therapy with acetaminophen as alternative or adjunct 1
   • Antibiotic therapy: Start immediately (within 1 hour) for suspected infection 1

2. Antibiotic Selection

   • First-line options for community-acquired cases:
     • Cefazolin (2g IV) or Cefuroxime (1.5g IV) 1
     • Add vancomycin for potential MRSA coverage in high-risk patients 1
   • For more severe infections: Consider broader coverage against gram-negative aerobes (E. coli, Klebsiella) and anaerobes (Bacteroides fragilis) 2
   • Healthcare-associated infections: Require broader spectrum coverage due to resistant strains 2

3. Diagnostic Imaging

   • Abdominal ultrasonography: First-line imaging with key findings including gallbladder wall thickening, pericholecystic fluid, distended gallbladder, and positive sonographic Murphy's sign 1
   • CT with IV contrast: Second-line imaging to detect complications 1

Definitive Management

1. Surgical Intervention

   • Early laparoscopic cholecystectomy (within 24-72 hours of diagnosis) is the treatment of choice 1, 3
   • Benefits include immediate stone removal, prevention of recurrent episodes, and elimination of gallbladder cancer risk 1
   • Optimal timeframe can be extended up to 7-10 days from symptom onset 3
   • No postoperative antibiotics needed when adequate source control is achieved 1

2. Management for High-Risk Patients

   • For patients who are poor surgical candidates (advanced age, severe comorbidities, septic shock):
     • Percutaneous cholecystostomy: Preferred transhepatic approach to minimize bile leakage 1
     • Consider delaying surgery at least 6 weeks after clinical presentation for those not eligible for early surgery 3

3. Special Considerations

   • Biliary pancreatitis: Cholecystectomy during initial admission strongly recommended 1
   • Cholangitis: Laparoscopic cholecystectomy should follow endoscopic management 1
   • Critically ill patients: May require gallbladder drainage as rescue treatment 3

Outcomes and Complications

• Early vs. late laparoscopic cholecystectomy is associated with fewer postoperative complications (11.8% vs 34.4%), shorter hospital stays (5.4 vs 10.0 days), and lower costs 4
• Mortality rates increase with male gender, advanced age, severe systemic disease 1
• 30-day mortality is higher in acalculous cholecystitis (45.2%) compared to calculous cholecystitis (21.2%) 1
• Untreated bile duct injuries can progress to secondary biliary cirrhosis, portal hypertension, liver failure, and death 1

Algorithm for Management

1. Diagnosis confirmed → Start antibiotics, fluids, and pain control
2. Assess surgical risk:
   • Low-risk patient → Early laparoscopic cholecystectomy (24-72 hours)
   • High-risk patient → Consider percutaneous cholecystostomy
3. After cholecystectomy → No antibiotics needed if adequate source control achieved
4. If drainage performed → Consider delayed cholecystectomy after 6 weeks when clinically stable

Early intervention is key to preventing complications and reducing mortality in acute cholecystitis, with laparoscopic cholecystectomy being the definitive treatment of choice for most patients.