What is the management plan for a symptomatic contracted gallbladder?

Management of Symptomatic Contracted Gallbladder

The definitive treatment for a symptomatic contracted gallbladder is laparoscopic cholecystectomy, which should be performed within 7-10 days of symptom onset for optimal outcomes. 1

Diagnostic Approach

Before proceeding with management, confirm the diagnosis with:

• Abdominal ultrasound: First-line imaging modality to evaluate gallbladder morphology, wall thickness, and presence of stones 1
• HIDA scan: Particularly useful for contracted gallbladder evaluation with 80-90% sensitivity; absence of gallbladder filling within 60 minutes indicates cystic duct obstruction 1
• Laboratory tests: Complete blood count and liver function tests to assess for inflammation and biliary obstruction 1

Management Algorithm

1. Initial Assessment

• Evaluate severity of symptoms (right upper quadrant pain, Murphy's sign, fever)
• Assess for complications (pericholecystic fluid, distended gallbladder, edematous wall)
• Determine if patient is critically ill or immunocompromised

2. Treatment Options

For Non-Critically Ill, Immunocompetent Patients:

• Early intervention (preferred): Laparoscopic cholecystectomy within 7-10 days of symptom onset 2
  • One-shot antibiotic prophylaxis only
  • No post-operative antibiotics needed if uncomplicated

For Complicated Cases or Critically Ill Patients:

• Laparoscopic cholecystectomy (with open conversion if needed)
• Antibiotic therapy for 4 days in immunocompetent patients with adequate source control 2
• Extended antibiotic therapy up to 7 days for immunocompromised or critically ill patients 2

For High-Risk Surgical Patients:

• Cholecystostomy may be considered for patients unfit for surgery who don't improve with antibiotic therapy 2
• Note: Cholecystostomy is inferior to cholecystectomy in terms of major complications for critically ill patients 2

3. Antibiotic Regimens

For non-critically ill patients:

• Amoxicillin/Clavulanate 2g/0.2g q8h 2
• For beta-lactam allergy: Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose then 50 mg q12h 2

For critically ill or immunocompromised patients:

• Piperacillin/tazobactam 6g/0.75g loading dose then 4g/0.5g q6h or 16g/2g by continuous infusion 2

Special Considerations

Surgical Approach

• Laparoscopic approach is preferred but may require conversion to open procedure if:
  • Severe local inflammation is present
  • Adhesions complicate visualization
  • Bleeding from Calot's triangle occurs
  • Bile duct injury is suspected 1

Post-Surgical Care

• Most patients can be discharged within 1-2 days after laparoscopic cholecystectomy
• Follow-up at 7-10 days post-surgery for wound evaluation 1
• Monitor for resolution of symptoms and signs of infection

Common Pitfalls to Avoid

1. Delayed intervention: Waiting too long increases risk of complications
2. Inadequate imaging: Failure to properly diagnose contracted gallbladder can lead to inappropriate management
3. Prolonged antibiotic use: Continuing antibiotics beyond 7 days without ongoing signs of infection is not recommended 2
4. Overlooking common bile duct stones: Consider MRCP if there is suspicion of common bile duct stones 2

Remember that frailty assessment is more important than chronological age when determining surgical risk, and age >65 years alone is not a contraindication to cholecystectomy 1.