What is the management of acute cholecystitis?

Management of Acute Cholecystitis

The definitive management of acute cholecystitis is early laparoscopic cholecystectomy performed within 72 hours of diagnosis, accompanied by appropriate antibiotic therapy, fluid resuscitation, and pain management. 1, 2

Initial Assessment and Medical Management

Diagnosis

• First-line imaging: Ultrasonography (sensitivity ~81%, specificity ~83%)
  • Key findings: gallstones, gallbladder wall thickening, pericholecystic fluid, distended gallbladder, positive sonographic Murphy's sign 1
• Second-line imaging: Hepatobiliary scintigraphy (HIDA scan) when ultrasound is inconclusive 1
• Additional imaging: Abdominal triphasic CT with IV contrast to detect complications (fluid collections, bilomas, ductal dilation) 1

Initial Medical Management

1. Fluid resuscitation: Goal-directed fluid therapy 1
2. Antibiotic therapy: Start within first hour if sepsis is present 1
   • First-line options:
     • Mild cases: Amoxicillin/Clavulanate, Ceftriaxone + Metronidazole, or Ciprofloxacin + Metronidazole
     • Severe cases: Piperacillin/Tazobactam 1
   • Duration: 3-5 days total course for complicated cholecystitis 1
   • Adjust based on culture results when available
3. Pain management: Oral NSAIDs as first-line therapy, with acetaminophen as alternative or adjunct 1
4. Fasting and bowel rest 2

Surgical Management

Early Laparoscopic Cholecystectomy

• Optimal timing: Within 72 hours of diagnosis, with possible extension up to 7-10 days from symptom onset 2
• Benefits: Lower mortality, better outcomes, prevents recurrence of symptoms and complications 1, 2
• Technique: Conventional laparoscopic 3-4 port cholecystectomy is the standard approach 3
• Conversion consideration: Low threshold for conversion to open procedure if severe inflammation, adhesions, or anatomical variations are encountered 1, 3

Special Populations

• Pregnancy: Early laparoscopic cholecystectomy recommended during all trimesters (1.6% maternal-fetal complications vs. 18.4% with delayed management) 1
• Elderly patients: Still benefit from early surgical intervention despite higher baseline risks 1, 4
• Acute biliary pancreatitis: Cholecystectomy during initial admission strongly recommended to prevent recurrence 1

Management of High-Risk or Critically Ill Patients

Alternative Approaches for Patients Unfit for Surgery

1. Percutaneous cholecystostomy:

   • First-line alternative for patients temporarily or permanently unfit for surgery 1, 4
   • Can serve as bridge to surgery or definitive treatment 4
   • Continue broad-spectrum antibiotics for 3-5 days 1
   • If used as bridge to surgery, delayed cholecystectomy recommended after at least 6 weeks 4

2. Endoscopic gallbladder drainage:

   • Second-line alternative, especially as definitive procedure 4
   • Options include cholecystoduodenostomy and cholecystogastrostomy 4

3. Trans-papillary gallbladder drainage:

   • Last option, reserved for patients unfit for other techniques 4

Long-term Management After Non-operative Treatment

• In patients who underwent drainage without subsequent cholecystectomy, recurrence rate is relatively low (7%) 5
• For patients who recover from their acute illness, delayed cholecystectomy should be considered 6
• For permanently unfit patients, gallstone removal using percutaneous tract or endoscopy may be considered 6

Monitoring and Complications

Monitoring

• Daily assessment of clinical response 1
• Monitoring of renal function, especially in elderly patients with CKD 1
• Adjust antibiotics based on culture results and clinical response 1

Potential Complications

• Gangrenous cholecystitis, emphysematous cholecystitis, gallbladder perforation (12-16% mortality), hemorrhagic cholecystitis 1
• Choledocholithiasis, cholangitis, gallstone pancreatitis, gallstone ileus 1
• Higher mortality in acalculous cholecystitis (45.2%) compared to calculous cholecystitis (21.2%) 1
• Bile duct injuries are among the most serious surgical complications 3

Pitfalls and Caveats

• Delaying surgery beyond 72 hours increases risk of complications and conversion to open procedure
• Antibiotic selection should consider local resistance patterns and patient factors (renal/hepatic function)
• In obese patients with severe hepatic disease, metronidazole metabolism may be slower; consider dose adjustment and monitoring 1
• Failure to obtain bile cultures when possible may lead to suboptimal antibiotic therapy
• Underestimating severity in elderly patients can lead to poor outcomes; they benefit from early intervention despite higher baseline risks