Initial Management of Acute Cholecystitis
Early laparoscopic cholecystectomy within 7-10 days of symptom onset is the gold standard treatment for acute cholecystitis and should be performed after initial medical management. 1
Clinical Presentation and Diagnosis
- Patients typically present with right upper quadrant abdominal pain, fever, and tenderness 1
- Murphy's sign (pain on palpation during inspiration) is characteristic 1
- Laboratory findings often include leukocytosis and elevated inflammatory markers 1
- Ultrasound is the investigation of choice for suspected acute cholecystitis, showing: 1
- Pericholecystic fluid
- Distended gallbladder
- Edematous gallbladder wall
- Gallstones (often impacted in cystic duct)
- Murphy's sign can be elicited on ultrasound examination
- CT with IV contrast or MRCP may be used when ultrasound is inconclusive or to evaluate for complications 1
Initial Medical Management
General Measures
- Hospitalization with nothing by mouth (NPO) 2
- Intravenous fluid resuscitation 1, 2
- Analgesia for pain control 3
- Nasogastric tube if ileus is present 2
Antimicrobial Therapy
- Antibiotic therapy should be started promptly and guided by the severity of illness and local resistance patterns 1
- For uncomplicated cholecystitis in stable, immunocompetent patients: 1
- Amoxicillin/clavulanate 2g/0.2g q8h
- Alternative if beta-lactam allergy: eravacycline 1 mg/kg q12h or tigecycline 100 mg loading dose then 50 mg q12h
- For complicated cholecystitis or critically ill/immunocompromised patients: 1
- Piperacillin/tazobactam 4g/0.5g q6h or 16g/2g by continuous infusion
- Alternative if beta-lactam allergy: eravacycline 1 mg/kg q12h
- For patients with septic shock: 1
- Meropenem 1g q6h by extended infusion or continuous infusion, or
- Doripenem 500mg q8h by extended infusion or continuous infusion, or
- Imipenem/cilastatin 500mg q6h by extended infusion
Definitive Management
Surgical Approach
- Early laparoscopic cholecystectomy (within 7-10 days of symptom onset) is the treatment of choice 1
- Early cholecystectomy results in shorter hospital stays and quicker recovery compared to delayed intervention 1, 4
- Postoperative antibiotics are not necessary in uncomplicated cholecystitis when the source of infection is controlled by cholecystectomy 1
Management in High-Risk Patients
- For patients unfit for surgery due to severe comorbidities (high ASA score, significant comorbidities): 1, 5
- Percutaneous cholecystostomy is recommended as a bridge to surgery or definitive treatment
- Endoscopic gallbladder drainage is an alternative when percutaneous approach is contraindicated
- If percutaneous cholecystostomy is performed: 5
- The drain should remain in place for at least 3 weeks
- For patients who improve, interval cholecystectomy can be considered after 6 weeks
- For patients permanently unfit for surgery, the drain can be removed after confirming biliary tree patency
Special Considerations
- In patients with concomitant choledocholithiasis and cholangitis, MRCP should be performed to evaluate the common bile duct 1
- Microbiological cultures should be obtained in complicated cases to guide targeted antibiotic therapy 1
- Antibiotics with good biliary penetration (piperacillin/tazobactam, tigecycline, amoxicillin/clavulanate, ciprofloxacin) should be preferred 1