What is the management of acute cholecystitis?

Management of Acute Cholecystitis

Early laparoscopic cholecystectomy within 7-10 days of symptom onset, combined with appropriate antibiotic therapy, is the primary treatment for acute cholecystitis. 1

Diagnosis

• First-line imaging: Ultrasonography with sensitivity ~81% and specificity ~83%
  • Key findings: gallstones, gallbladder wall thickening, pericholecystic fluid, distended gallbladder, and 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 like fluid collections, bilomas, ductal dilation, and vascular injuries 1

Treatment Algorithm

1. Initial Management

• NPO (nothing by mouth)
• Intravenous fluid resuscitation with goal-directed fluid therapy 1
• Pain management:
  • First-line: NSAIDs 1
  • Alternative/adjunct: Acetaminophen 1
• Antibiotic therapy:
  • First-line options: 1
    • Amoxicillin/Clavulanate 2g/0.2g q8h
    • Ceftriaxone + Metronidazole
    • Ciprofloxacin + Metronidazole
    • Levofloxacin + Metronidazole
  • For healthcare-associated infections or complicated cases:
    • Piperacillin/Tazobactam 1
  • Duration: Typically 4 days if source control is adequate; may extend to 7 days based on clinical condition 1

2. Definitive Treatment

• Standard approach: Early laparoscopic cholecystectomy within 72 hours of diagnosis, with possible extension up to 7-10 days from symptom onset 1, 2
• Surgical prophylaxis: Single 1 gram dose of Ceftriaxone preoperatively 3
• Surgical considerations:
  • Subtotal cholecystectomy (laparoscopic or open) for advanced inflammation, gangrenous gallbladder, or difficult anatomy 1
  • Convert to open surgery if severe local inflammation, adhesions, bleeding in Calot triangle, or suspected bile duct injury 1

3. Alternative Management for High-Risk Patients

• High-risk patients: Advanced cirrhosis, biliary sepsis, severe inflammation, difficult anatomy, significant comorbidities, age >65 years, Child-Pugh C cirrhosis, ASA III/IV classification, poor functional status, or septic shock 1
• Options:
  • Percutaneous cholecystostomy for patients unfit for surgery who don't improve with antibiotics 1, 4
  • Delayed surgery (at least 6 weeks after clinical presentation) for those not eligible for early surgery 2

Special Considerations

• Elderly patients:

  • Require special consideration due to altered pharmacokinetics 1
  • May need dose adjustments for medications 1
  • Early cholecystectomy still preferred with lower mortality and better outcomes 1

• Patients with renal/hepatic dysfunction:

  • Require careful monitoring and potential dose adjustments 1
  • For obese patients with severe hepatic disease, administer metronidazole at lower doses with close monitoring 1

Complications and Risks

• Surgical complications:

  • Bile duct injuries (most serious complication) 1, 5
  • Wound infections 6
  • Retained stones 6

• Disease complications:

  • Gangrenous cholecystitis
  • Emphysematous cholecystitis
  • Gallbladder perforation
  • Hemorrhagic cholecystitis 1
  • Higher mortality rates in acalculous cholecystitis (45.2%) compared to calculous cholecystitis (21.2%) 1

Important Caveats

• Timing is critical: Delaying surgery beyond the recommended timeframe increases risk of recurrence (24% recurrence rate in delayed surgery) 6
• Failed medical treatment: Conservative management alone carries risks of peritonitis, increasing jaundice, and mortality 6
• Post-drainage management: After percutaneous cholecystostomy and recovery, patients should be evaluated for definitive cholecystectomy unless surgical risks remain prohibitively high 7, 4
• Daily monitoring: Assess clinical response and renal function daily, especially in elderly patients with chronic kidney disease 1
• Extended antibiotic duration: Consider further diagnostic investigation if signs of infection persist beyond 7 days 1