Management of Acute Cholecystitis
Early laparoscopic cholecystectomy within 72 hours of diagnosis (up to 7-10 days from symptom onset) combined with appropriate antibiotic therapy is the gold standard treatment for acute cholecystitis. 1, 2
Clinical Presentation and Diagnosis
Symptoms and Signs
- Right upper quadrant pain
- Murphy's sign (pain on palpation during inspiration)
- Fever
- Abdominal tenderness 1
Diagnostic Workup
First-line imaging: Ultrasonography (sensitivity ~81%, specificity ~83%)
- Key findings: gallstones, gallbladder wall thickening, pericholecystic fluid, distended gallbladder, sonographic Murphy's sign 1
Second-line imaging (when ultrasound is inconclusive):
Treatment Algorithm
1. Initial Management
- NPO (nothing by mouth)
- Intravenous fluid resuscitation using goal-directed therapy 1, 3
- Antibiotic therapy (start immediately upon diagnosis)
- Pain management: NSAIDs as first-line therapy, with acetaminophen as alternative/adjunct 1
2. Definitive Treatment
- Early laparoscopic cholecystectomy (within 72 hours of diagnosis, up to 7-10 days from symptom onset) 2, 1, 3
3. Alternative Approaches
- Open cholecystectomy: When laparoscopic approach is not feasible 1
- Percutaneous cholecystostomy: For high-risk patients unfit for surgery who don't improve with antibiotics 1
- Note: This is inferior to cholecystectomy in terms of major complications for critically ill patients 1
4. Special Populations
- Elderly patients: Early laparoscopic cholecystectomy still recommended with appropriate perioperative care 1
- Pregnant patients: Early laparoscopic cholecystectomy recommended during all trimesters
- Lower risk of maternal-fetal complications (1.6%) compared to delayed management (18.4%) 1
Antibiotic Therapy
First-line Options
- Amoxicillin/Clavulanate 2g/0.2g q8h 1
- Ceftriaxone + Metronidazole
- Ciprofloxacin + Metronidazole
- Levofloxacin + Metronidazole
- Moxifloxacin
- Ertapenem
- Tigecycline 1
For Healthcare-Associated Infections or Complicated Cases
- Piperacillin/Tazobactam 1
- Add coverage against Enterococci (vancomycin or linezolid) when indicated 1
Duration
- Typically 4 days if source control is adequate
- May extend up to 7 days based on clinical condition and inflammatory markers 1
Risk Factors for Failed Conservative Management
Patients with the following factors are at higher risk for failed conservative treatment and should be considered for early intervention:
- Age above 70 years
- Diabetes
- Tachycardia at admission (>100 beats/min)
- Distended gallbladder (>5 cm transverse diameter)
- Persistently elevated WBC count (>15,000) after 24-48 hours 4
Complications to Monitor For
- Bile duct injuries (most serious complication of laparoscopic cholecystectomy)
- Gangrenous cholecystitis
- Emphysematous cholecystitis
- Gallbladder perforation
- Hemorrhagic cholecystitis 1
Monitoring and Follow-up
- Daily assessment of clinical response
- Monitor renal function, especially in elderly patients with CKD
- Patients with ongoing signs of infection beyond 7 days warrant further diagnostic investigation 1
- For patients who undergo percutaneous drainage rather than cholecystectomy, consider definitive treatment after recovery from acute episode 5
Important Caveats
- The 2020 World Society of Emergency Surgery guidelines emphasize that cholecystectomy is the standard of care for the majority of patients with acute cholecystitis 2
- Early cholecystectomy has been shown to have better outcomes than delayed surgery since at least the 1970s, with lower complication rates and shorter operative times 6
- In patients truly unfit for surgery, gallstone removal using percutaneous tract or endoscopy may be considered as an alternative to cholecystectomy 5
- Proper training and technique are essential to minimize the risk of bile duct injuries during laparoscopic cholecystectomy 7