What are the management recommendations for acute cholecystitis?

Management of Acute Cholecystitis

Early laparoscopic cholecystectomy within 72 hours of diagnosis is the gold standard treatment for acute cholecystitis, with antibiotic therapy tailored to severity and patient factors. 1

Initial Assessment and Management

Surgical Intervention

1. Timing of Surgery:

   • Early laparoscopic cholecystectomy (within 72 hours of diagnosis) is the gold standard treatment 1, 2
   • Can be extended up to 7-10 days from symptom onset if necessary 1, 2
   • For patients not eligible for early surgery, delay cholecystectomy for at least 6 weeks after clinical presentation 2

2. Surgical Considerations:

   • Subtotal cholecystectomy (laparoscopic or open) is valid for cases with advanced inflammation, gangrenous gallbladder, or difficult anatomy 1
   • Laparoscopic cholecystectomy is safe during pregnancy, ideally in second trimester but can be performed in any trimester if necessary 1

Antibiotic Therapy

1. Non-critically ill, immunocompetent patients:

   • First-line: Amoxicillin/Clavulanate 2g/0.2g q8h 1
   • Alternatives: Ceftriaxone + Metronidazole, Ciprofloxacin + Metronidazole, Levofloxacin + Metronidazole, Moxifloxacin, Ertapenem, or Tigecycline 1

2. Critically ill or immunocompromised patients:

   • Piperacillin/Tazobactam 6g/0.75g LD then 4g/0.5g q6h or 16g/2g by continuous infusion 1
   • For healthcare-associated biliary infections and complicated cholecystitis 1

3. Beta-lactam allergy:

   • Eravacycline 1mg/kg q12h or Tigecycline 100mg LD then 50mg q12h 1

4. Special considerations:

   • Add coverage against Enterococci with glycopeptide antibiotics (e.g., vancomycin) or oxazolidine antibiotics (e.g., linezolid) when indicated 1
   • Elderly patients (>65 years) require careful antibiotic management due to altered pharmacokinetics 1

Antibiotic Duration

• After adequate source control (cholecystectomy):
  • 4 days for immunocompetent, non-critically ill patients 1, 3
  • Up to 7 days for immunocompromised or critically ill patients 1
• For uncomplicated cases with non-surgical management: up to 7 days 1
• No post-operative antibiotics needed if procedure is uncomplicated 1, 3
• Maximum of 4 days of antibiotics for severe (Tokyo Guidelines grade III) cholecystitis 3

Management of High-Risk Patients

For patients unfit for surgery (particularly those over 65 years with ASA III/IV status or septic shock):

• Percutaneous cholecystostomy (PC) as:
  • Bridge to interval cholecystectomy 1, 2, 4
  • Definitive treatment for those permanently unfit for surgery 1
• Endoscopic gallbladder drainage is an alternative option 4
• Continue antibiotic therapy for 4 days if source control is adequate 1

Diagnostic Imaging

• First-line: Ultrasonography (sensitivity ~81%, specificity ~83%) 1
• If ultrasound inconclusive: Hepatobiliary scintigraphy (HIDA scan) 1
• For detecting cholelithiasis/choledocholithiasis: MRI with MRCP (sensitivity 85-100%) 1
• For detecting complications: CT with IV contrast (sensitivity ~75% for gallstones) 1

Pain Management and Supportive Care

• First-line pain management: Oral NSAIDs 1
• Alternative/adjunct: Acetaminophen 1
• Initial management includes fasting, intravenous fluid infusion 2
• Goal-directed fluid therapy for resuscitation 1

Complications and Monitoring

• Watch for bile duct injuries during laparoscopic cholecystectomy 1
• Potential complications include gangrenous cholecystitis, emphysematous cholecystitis, gallbladder perforation, and hemorrhagic cholecystitis 1
• PC complications (3.4-25.9%) include bile duct leak, biliary peritonitis, vessel injury, catheter dislodgement, colon injury, and vagal reaction 1
• If ongoing signs of infection beyond 7 days of antibiotic treatment, further diagnostic investigation is warranted 1

Microbiology Considerations

• Recent trends show declining frequency of enterococci and increasing Enterobacteriales, particularly Escherichia coli 5
• Increasing incidence of ciprofloxacin-resistant Enterobacteriales 5
• Emerging concerns include vancomycin-resistant E. faecium, carbapenem-resistant Enterobacteriales, and extended-spectrum beta-lactamase-producing Enterobacteriales 5

Evidence Quality and Pitfalls

• Early surgery has been shown to be superior to delayed surgery since the 1970s, with shorter operation times and fewer complications 6
• In grade I and II acute cholecystitis, surgery is crucial for infection control, even without early appropriate antimicrobial therapy 5
• The Surgical Infection Society recommends against routine use of perioperative antibiotics in low-risk patients undergoing elective laparoscopic cholecystectomy 3
• Failure to recognize and treat concomitant conditions such as choledocholithiasis, cholangitis, or biliary pancreatitis can lead to poor outcomes 2