What is the immediate management for a patient diagnosed with cholecystitis?

Immediate Management of Cholecystitis

Early laparoscopic cholecystectomy within 24-72 hours of diagnosis is the definitive treatment of choice for uncomplicated cholecystitis, accompanied by immediate initiation of broad-spectrum antibiotics, fluid resuscitation, and pain management. 1

Initial Medical Management

Fluid Resuscitation and Pain Control

• Goal-directed fluid therapy should be initiated immediately 1
• Pain management should begin with oral NSAIDs as first-line therapy, with acetaminophen as an alternative or adjunct 1

Antibiotic Therapy

• Initiate broad-spectrum antibiotics immediately (within 1 hour) if imaging shows evidence of biliary fistula, biloma, or bile peritonitis 1
• For mild-to-moderate community-acquired cases:
  • First-line options: Cefazolin (2g IV) or Cefuroxime (1.5g IV)
  • Add vancomycin for potential MRSA coverage in high-risk patients 1
• For severe infections, use broader coverage against gram-negative aerobes (E. coli, Klebsiella) and anaerobes (Bacteroides fragilis) 1
• Healthcare-associated infections require broader spectrum coverage due to resistant strains 1

Diagnostic Imaging

• Abdominal ultrasonography is the first-line imaging technique with key findings including:
  • Gallbladder wall thickening
  • Pericholecystic fluid
  • Distended gallbladder
  • Positive sonographic Murphy's sign 1
• If ultrasound is inconclusive, hepatobiliary scintigraphy (HIDA scan) is the gold standard diagnostic test 2
• Abdominal triphasic CT with IV contrast can detect fluid collections, bilomas, ductal dilation, and vascular injuries 1

Definitive Management

Surgical Approach

• Early laparoscopic cholecystectomy (ELC) should be performed as soon as possible:
  • Within 7 days from hospital admission
  • Within 10 days from the onset of symptoms 3
• ELC is preferable to intermediate laparoscopic cholecystectomy (performed between 7 days and 6 weeks) and delayed laparoscopic cholecystectomy (performed between 6 weeks and 3 months) 3
• Early intervention (within 24-72 hours) provides:
  • Immediate and permanent stone removal
  • Prevention of recurrent episodes of biliary pain
  • Elimination of gallbladder cancer risk 1
  • Fewer postoperative complications (11.8% for early vs 34.4% for late)
  • Shorter hospital stays (5.4 days vs 10.0 days)
  • Lower hospital costs 2

Special Populations

• Pregnancy: Early laparoscopic cholecystectomy is recommended during all trimesters, with lower risk of maternal-fetal complications (1.6% for early vs 18.4% for delayed) 2
• Elderly (>65 years): Laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared to nonoperative management (29.3%) 2
• High-risk patients: Consider percutaneous cholecystostomy for patients with:
  • Advanced age
  • Severe comorbidities
  • Septic shock
  • Other high surgical risk factors 1

Management of Complications

• If bile duct injury is suspected:
  • Initial observation and nonoperative management if a drain is present and bile leak is noted
  • Percutaneous drainage of collections if no drain was placed
  • ERCP with biliary sphincterotomy and stent placement if no improvement occurs
  • Referral to a center with hepatobiliary expertise for urgent surgical repair if diagnosed within 72 hours 1

Important Clinical Considerations

• Postoperative antibiotics are NOT recommended when the source of infection is controlled by cholecystectomy 1
• Cholecystectomy during the initial admission is strongly recommended for patients with acute biliary pancreatitis to prevent recurrent episodes 1
• Be aware that acute cholecystitis may present atypically without classic findings such as leukocytosis, fever, right upper quadrant pain, or positive Murphy's sign 4
• Untreated bile duct injuries can progress to secondary biliary cirrhosis, portal hypertension, liver failure, and death 1
• Mortality rates increase with male gender, advanced age, severe systemic disease, and common bile duct exploration 1