What is the treatment for acute cholecystitis?

Treatment of Acute Cholecystitis

Early laparoscopic cholecystectomy is the treatment of choice for acute cholecystitis and should be performed as soon as possible, within 7 days from hospital admission and within 10 days from the onset of symptoms. 1

Diagnosis

• Acute cholecystitis is diagnosed based on clinical features including right upper quadrant pain, fever, and leukocytosis, supported by imaging findings 1
• Ultrasound is the investigation of choice with typical findings including pericholecystic fluid, distended gallbladder, edematous gallbladder wall, gallstones, and Murphy's sign 1
• When ultrasound results are inconclusive, hepatobiliary scintigraphy can be used as a gold standard diagnostic test 2

Treatment Algorithm

First-line Treatment: Early Laparoscopic Cholecystectomy

• Early laparoscopic cholecystectomy (ELC) should be performed within 7 days of hospital admission and within 10 days from symptom onset 1

• ELC is associated with:

  • Shorter recovery time and hospitalization compared to delayed cholecystectomy 1
  • Lower hospital costs 1
  • Fewer work days lost 1
  • Greater patient satisfaction 1
  • Reduced risk of recurrent gallstone-related complications 1, 3

• For uncomplicated cholecystitis with complete source control, no postoperative antimicrobial therapy is necessary 1

Alternative Timing: Delayed Laparoscopic Cholecystectomy

• If ELC cannot be performed within the optimal timeframe, delayed laparoscopic cholecystectomy (DLC) should be performed after at least 6 weeks from the first clinical presentation 1
• Note that DLC is associated with:
  • Longer total hospital stay (approximately 4 days longer than ELC) 1
  • Delayed return to work (approximately 9 days later than ELC) 1
  • Higher risk of recurrent gallstone-related complications during the waiting period 3, 4

Special Populations and Situations

High-Risk Patients

• Immediate laparoscopic cholecystectomy is superior to percutaneous transhepatic gallbladder drainage (PTGBD) even in high-risk patients with ACC 1
• Laparoscopic cholecystectomy is associated with fewer major complications (5% vs 53%) compared to PTGBD in critically ill patients 1
• For elderly patients (>65 years), laparoscopic cholecystectomy is associated with lower 2-year mortality (15.2%) compared to nonoperative management (29.3%) 2

Critically Ill Patients Unfit for Surgery

• Gallbladder drainage (cholecystostomy) is recommended for patients who are not suitable for surgery 1
• Percutaneous cholecystostomy tube placement converts a septic patient with ACC into a non-septic patient by decompressing the infected bile or pus 1
• However, percutaneous drainage should be considered a bridge to surgery rather than definitive treatment due to frequent recurrence 4
• Percutaneous cholecystostomy is associated with higher rates of postprocedural complications (65%) compared to laparoscopic cholecystectomy (12%) 2

Gallbladder Perforation

• Early diagnosis of gallbladder perforation and immediate surgical intervention is crucial to decrease morbidity and mortality rates 1
• Reported incidence of gallbladder perforation in acute cholecystitis is 2-11% with mortality as high as 12-16% 1

Conservative Management Considerations

• Conservative management with fluids, analgesia, and antibiotics may be considered for patients with mildly symptomatic acute cholecystitis 1
• However, long-term follow-up shows that about 30% of conservatively treated patients develop recurrent gallstone-related complications and 60% eventually undergo cholecystectomy 1
• Initial management before surgery includes:
  • Fasting
  • Intravenous fluid infusion
  • Antimicrobial therapy
  • Analgesics 3

Technical Considerations

• Laparoscopic approach is preferred, but certain risk factors may predict conversion to open cholecystectomy 1
• Risk factors for conversion include: age >65 years, male gender, acute cholecystitis, thickened gallbladder wall, diabetes mellitus, and previous upper abdominal surgery 1
• Conversion to open surgery is not a failure but a valid option when necessary for patient safety 1
• Surgeons should adopt a philosophy of safe laparoscopic cholecystectomy to avoid bile duct injuries, which are among the most serious complications 5

In conclusion, early laparoscopic cholecystectomy within 10 days of symptom onset represents the optimal treatment for acute cholecystitis, with alternative approaches reserved for specific clinical scenarios where early surgery is not feasible.