What is the treatment for cholecystitis?

Treatment of Cholecystitis

Urgent laparoscopic cholecystectomy is the preferred treatment for acute cholecystitis and should be performed within 72 hours of diagnosis, with a possible extension up to 7-10 days from symptom onset. 1, 2

Diagnosis

Before initiating treatment, proper diagnosis is essential:

• Clinical features: Right upper quadrant pain, fever, and leukocytosis
• Imaging:
  • Ultrasonography is first-line (sensitivity ~81%, specificity ~83%) 1
  • Key findings: gallstones, gallbladder wall thickening, pericholecystic fluid, distended gallbladder, and positive sonographic Murphy's sign
  • Hepatobiliary scintigraphy (HIDA scan) is the gold standard when ultrasound is inconclusive 1, 3

Treatment Algorithm

1. Initial Medical Management

• Fasting
• Intravenous fluid resuscitation (goal-directed therapy) 1
• Antimicrobial therapy:
  • First-line options: Amoxicillin/Clavulanate, Ceftriaxone + Metronidazole, Ciprofloxacin + Metronidazole 1
  • For healthcare-associated infections: Piperacillin/Tazobactam 1
  • Duration: 3-5 days after successful intervention 1
• Pain management: NSAIDs as first-line, acetaminophen as alternative 1

2. Definitive Treatment

• Early laparoscopic cholecystectomy (within 72 hours of diagnosis) 1, 2, 3

  • Associated with fewer complications (11.8% vs 34.4% for delayed surgery)
  • Shorter hospital stay (5.4 vs 10.0 days)
  • Lower hospital costs 3

• If surgery must be delayed beyond 10 days, it's better to wait at least 6 weeks after the clinical presentation 2

3. Alternative Treatments for High-Risk Patients

• Percutaneous cholecystostomy for critically ill patients unfit for surgery 4, 1, 5
  • Note: Associated with higher complication rates (65%) compared to laparoscopic cholecystectomy (12%) 3
• Open cholecystectomy may be necessary in cases of severe inflammation, adhesions, or anatomical variations 1
• Mini laparotomy cholecystectomy may be appropriate in resource-constrained settings 4

Special Populations

Pregnant Women

• Early laparoscopic cholecystectomy is recommended during all trimesters
• Lower risk of maternal-fetal complications (1.6%) compared to delayed management (18.4%) 1, 3

Elderly Patients

• Laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared to nonoperative management (29.3%) 3
• Careful monitoring of renal function and appropriate dose adjustments of medications 1

Acalculous Cholecystitis

• Represents 5-10% of cholecystitis cases 3
• Higher mortality rate (45.2%) compared to calculous cholecystitis (21.2%) 1
• Laparoscopic cholecystectomy is recommended except in severely ill patients, who may benefit from percutaneous cholecystostomy 3

Complications to Monitor

• Gangrenous cholecystitis
• Emphysematous cholecystitis
• Gallbladder perforation
• Hemorrhagic cholecystitis 1

Common Pitfalls and Caveats

• Delaying surgery beyond 72 hours increases complication rates
• Unnecessary prolonged antibiotic therapy increases the risk of resistance 1
• Bile duct injuries are among the most serious complications of laparoscopic cholecystectomy 6
• Concomitant conditions such as choledocholithiasis, cholangitis, and biliary pancreatitis must be recognized and adequately treated 2

The evidence strongly supports early laparoscopic cholecystectomy as the standard of care for acute cholecystitis, with appropriate medical management including antibiotics, fluid resuscitation, and pain control in the perioperative period.