From the Guidelines
Cholecystectomy is indicated for symptomatic gallstone disease, including biliary colic, acute cholecystitis, gallstone pancreatitis, and choledocholithiasis, as well as for gallbladder polyps larger than 1 cm, porcelain gallbladder, and gallbladder cancer. The procedure is also recommended for patients with acute calculous cholecystitis, as it is the preferred treatment, even in elderly patients 1.
Indications for Cholecystectomy
- Symptomatic gallstone disease
- Biliary colic
- Acute cholecystitis
- Gallstone pancreatitis
- Choledocholithiasis
- Gallbladder polyps larger than 1 cm
- Porcelain gallbladder
- Gallbladder cancer
Considerations for Acute Cholecystitis
- Early cholecystectomy (within 24-72 hours of symptom onset) is preferred when possible, as it reduces overall complications and hospital stay compared to delayed surgery 1.
- Laparoscopic cholecystectomy is the standard approach, with conversion to open procedure reserved for cases with severe inflammation, unclear anatomy, or complications.
- Before surgery, patients typically undergo imaging studies like ultrasound or MRCP to confirm diagnosis and assess for common bile duct stones.
- Preoperative antibiotics are administered for acute cholecystitis, with regimens typically including a cephalosporin plus metronidazole for broad-spectrum coverage.
Special Considerations
- Asymptomatic gallstones generally do not require surgery unless the patient has specific risk factors such as diabetes, immunosuppression, or sickle cell disease.
- In patients with acute biliary pancreatitis, cholecystectomy during the initial admission is recommended rather than after discharge 1.
- Cholecystostomy is a safe and effective treatment for acute cholecystitis in critically ill and/or patients with multiple comorbidities and unfit for surgery 1.
Surgical Approach
- Laparoscopic cholecystectomy is a safe and effective treatment for acute cholecystitis, and is the first choice for patients with acute cholecystitis where adequate resources and skill are available 1.
- Open cholecystectomy remains a feasible option, particularly in low-income countries or in the setting of resource limitations.
From the FDA Drug Label
Ursodiol capsules are indicated for patients with radiolucent, noncalcified gallbladder stones < 20 mm in greatest diameter in whom elective cholecystectomy would be undertaken except for the presence of increased surgical risk due to systemic disease, advanced age, idiosyncratic reaction to general anesthesia, or for those patients who refuse surgery.
The indications for a cholecystectomy (surgical removal of the gallbladder) are not directly stated in the drug label, but it can be inferred that a cholecystectomy would be considered for patients with:
- Radiolucent, noncalcified gallbladder stones < 20 mm in greatest diameter In the absence of increased surgical risk or other contraindications, such as:
- Systemic disease
- Advanced age
- Idiosyncratic reaction to general anesthesia However, this information is indirect and the label does not provide a clear answer to the question about indications for cholecystectomy. The FDA drug label does not answer the question.
From the Research
Indications for Cholecystectomy
The indications for a cholecystectomy, or the surgical removal of the gallbladder, include:
- Asymptomatic gallstone disease, where therapeutic decisions are clear-cut 2
- Acute cholecystitis, where cholecystectomy is the intervention of choice when conservative management does not work 3
- Chronic cholecystitis, where watchful waiting may be reasonable for patients with mild and infrequent symptoms, but cholecystectomy is recommended if symptoms become more frequent and severe 2
- Gallstone-related disease, including biliary colic, acute cholecystitis, gallstone pancreatitis, and obstructive jaundice, where early laparoscopic cholecystectomy is recommended to prevent recurrent presentations and complications 4
- Symptomatic gallstone disease, where certain patients benefit from same-admission cholecystectomy instead of delayed cholecystectomy 5
- Complicated symptomatic gallstone disease, such as common bile duct stones and biliary pancreatitis, where same-admission cholecystectomy reduces the risk of recurrent complications 5
- Symptomatic cholelithiasis in cirrhotic patients, where cholecystectomy is considered due to the high risk of complications and the potential for systemic effects and local anatomic consequences related to cirrhosis 6
Specific Conditions
Cholecystectomy may be indicated in specific conditions, such as:
- Mirizzi's syndrome, where a calculus is jammed in the vesicular infundibulum, causing compression and increase in pressure in the bile duct 3
- Charcot's Triad, where patients present with jaundice, fever, and pain in the right hypochondrium, which can progress to sepsis of biliary origin 3
- Cholechodocolithiasis, where a stone is lodged in the common bile duct, and endoscopic papillotomy through endoscopic retrograde cholangiopancreatography (ERCP) may be performed before or after cholecystectomy 3
Timing of Cholecystectomy
The timing of cholecystectomy is important, and early laparoscopic cholecystectomy is recommended for:
- Acute gallstone-related disease, to prevent recurrent presentations and complications 4
- Symptomatic gallstone disease, where same-admission cholecystectomy reduces the risk of recurrent complications 5
- Complicated symptomatic gallstone disease, such as common bile duct stones and biliary pancreatitis, where same-admission cholecystectomy reduces the risk of recurrent complications 5