What is the treatment for cholecystitis?

Treatment of Cholecystitis

Early laparoscopic cholecystectomy is the gold standard treatment for acute cholecystitis and should be performed within 7 days of hospital admission and within 10 days from symptom onset. 1

Initial Management

• Begin with supportive care while preparing for surgery:
  • Fasting 2
  • Intravenous fluid resuscitation 2
  • Antimicrobial therapy for infection control 1
  • Pain management with multimodal analgesia 3
    • Opioids for severe pain 3
    • Acetaminophen (1g every 6 hours) 3
    • NSAIDs for moderate pain when not contraindicated 3

Surgical Management

• Early laparoscopic cholecystectomy (ELC) is superior to delayed laparoscopic cholecystectomy (DLC) with:

  • Shorter recovery time and hospitalization 4
  • Lower hospital costs 1
  • Fewer work days lost 1
  • Greater patient satisfaction 4
  • Reduced risk of recurrent gallstone-related complications 1

• For uncomplicated cholecystitis with complete source control, no postoperative antimicrobial therapy is necessary 4

• Risk factors that may predict conversion to open cholecystectomy:

  • Age >65 years 4
  • Male gender 4
  • Acute cholecystitis 4
  • Thickened gallbladder wall 4
  • Diabetes mellitus 4
  • Previous upper abdominal surgery 4

Management in High-Risk Patients

• Cholecystostomy (gallbladder drainage) is recommended for patients who are critically ill or have multiple comorbidities making them unfit for surgery 4, 1

• Consider cholecystostomy for:

  • Patients with severe acute cholecystitis who are high-surgical risk 5
  • Patients with Charlson Comorbidity Index ≥6 and ASA-PS ≥4 5

• For patients who undergo cholecystostomy:

  • If suitable for delayed surgery, perform laparoscopic cholecystectomy at least six weeks after cholecystostomy placement 5
  • If not suitable for surgery, leave cholecystostomy tube in place for at least three weeks 5
  • After confirming biliary tree patency, the tube may be removed in patients not suitable for surgery 5

Special Considerations

• Early diagnosis of gallbladder perforation and immediate surgical intervention is crucial to decrease morbidity and mortality 4

• Conservative management with antibiotics and supportive care should be considered only as a bridge to surgery rather than definitive treatment due to high recurrence rates 6

• Long-term follow-up shows that approximately 30% of conservatively treated patients develop recurrent gallstone-related complications, and 60% eventually undergo cholecystectomy 1

Antimicrobial Considerations

• Ceftriaxone can be used for surgical prophylaxis in patients undergoing cholecystectomy, particularly in high-risk patients such as those over 70 years of age with acute cholecystitis 7

• For patients with intra-abdominal infections related to cholecystitis, antimicrobial therapy should target common biliary pathogens including Escherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, and Clostridium species 7

Complications and Prevention

• Laparoscopic cholecystectomy, while safe and effective, can be associated with complications including bile duct injuries 8

• To minimize complications:

  • Ensure proper training in laparoscopic techniques 8
  • Have a low threshold for conversion to open surgery when necessary 8
  • Recognize risk factors for difficult cholecystectomy 4