Who should be consulted for acute cholecystitis, Gastroenterology (GI) or General Surgery?

From the Guidelines

For acute cholecystitis, you should consult General Surgery first, as the current guidelines recommend surgery as the primary treatment for this condition. Acute cholecystitis is primarily a surgical condition that often requires cholecystectomy (gallbladder removal) as definitive treatment 1. Surgeons are trained to evaluate the severity of the condition, determine if immediate surgical intervention is needed, and manage complications like perforation or gangrene. While Gastroenterology (GI) specialists can help with diagnosis through endoscopic procedures and may assist with non-surgical management in patients who are poor surgical candidates, they typically aren't the primary service for acute cholecystitis.

The standard treatment pathway involves initial stabilization with IV fluids, antibiotics (often a combination covering enteric gram-negative bacteria and anaerobes, such as piperacillin-tazobactam or ceftriaxone plus metronidazole), pain management, and then surgical evaluation for cholecystectomy, ideally within 24-72 hours of symptom onset 1. Key points to consider include:

• The 2020 World Society of Emergency Surgery guidelines recommend surgery as the primary treatment for acute cholecystitis, with a preference for laparoscopic cholecystectomy over open cholecystectomy 1.
• Early laparoscopic cholecystectomy (ELC) is recommended within 7 days of hospital admission and within 10 days of onset of symptoms, as it has been shown to reduce hospital stay and improve outcomes compared to delayed laparoscopic cholecystectomy (DLC) or intermediate laparoscopic cholecystectomy (ILC) 1.
• If ELC cannot be performed, DLC may be considered, although the evidence for this approach is weaker 1.
• A multidisciplinary approach involving both General Surgery and Gastroenterology may be appropriate in certain cases, such as patients with unusual comorbidities or those who require endoscopic procedures for diagnosis or treatment 1.

Overall, the current evidence supports a surgical approach as the primary treatment for acute cholecystitis, with General Surgery playing a key role in the management of this condition.

From the FDA Drug Label

SURGICAL PROPHYLAXIS The preoperative administration of a single 1 gram dose of Ceftriaxone for Injection may reduce the incidence of postoperative infections in patients undergoing surgical procedures classified as contaminated or potentially contaminated (e.g., vaginal or abdominal hysterectomy or cholecystectomy for chronic calculous cholecystitis in high-risk patients, such as those over 70 years of age, with acute cholecystitis not requiring therapeutic antimicrobials, obstructive jaundice or common duct bile stones)

For acute cholecystitis, patients should be consulted with General Surgery 2.

From the Research

Diagnosis and Treatment of Acute Cholecystitis

For acute cholecystitis, the following points should be considered:

• The gold standard treatment for acute cholecystitis is laparoscopic cholecystectomy 3, 4, 5
• Early laparoscopic cholecystectomy is the preferred procedure for mild acute cholecystitis 6
• For patients with severe local inflammation, early gallbladder drainage or open cholecystectomy is indicated 6
• Percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage may be a temporary therapeutic option for critically ill patients 4

Consultation for Acute Cholecystitis

Based on the evidence, the following points should be considered:

• Patients with acute cholecystitis should be consulted by General Surgery, as laparoscopic cholecystectomy is the treatment of choice 3, 6, 4, 5, 7
• Gastroenterology (GI) may be involved in the diagnosis and management of concomitant conditions such as choledocholithiasis, cholangitis, or biliary pancreatitis 3
• However, the primary consultation for acute cholecystitis should be with General Surgery, as they will perform the laparoscopic cholecystectomy 3, 6, 4, 5, 7

Special Considerations

The following special considerations should be taken into account:

• High-risk patients, such as the elderly with severe comorbidities, may require a temporary therapeutic option, such as percutaneous cholecystostomy or endoscopic ultrasound gallbladder drainage 4
• Pregnant women, cirrhotic, and elderly patients may require a particular treatment approach 3
• The optimal treatment modality for high-surgical-risk patients should be individualized based on clinical conditions and available expertise 4