What is the management of acute cholecystitis?

Management of Acute Cholecystitis

Early laparoscopic cholecystectomy (within 7 days of symptom onset) is the treatment of choice for acute cholecystitis and should be performed as soon as possible after diagnosis. 1, 2

Diagnosis

• Diagnosis is based on clinical features including right upper quadrant pain, fever, and leukocytosis 2
• Murphy's sign (pain on palpation during inspiration) is a characteristic finding 2
• Ultrasound is the investigation of choice, showing:
  • Pericholecystic fluid
  • Distended gallbladder
  • Edematous gallbladder wall (≥5mm thickness)
  • Gallstones
  • Ultrasonographic Murphy's sign 1, 2
• Hepatobiliary scintigraphy can be used when ultrasound is inconclusive, with absence of gallbladder filling within 60 minutes indicating cystic duct obstruction (80-90% sensitivity) 1

Initial Medical Management

• Start with:
  • Fasting
  • Intravenous fluid resuscitation
  • Pain management
  • Antimicrobial therapy 3
• Antibiotic selection should be based on:
  • Origin of infection (community vs. healthcare-acquired)
  • Severity of illness
  • Local resistance patterns 2
• For uncomplicated cholecystitis in stable patients:
  • Amoxicillin/clavulanate 2g/0.2g q8h 2
• For complicated cholecystitis or critically ill patients:
  • Piperacillin/tazobactam or carbapenems 2, 4

Definitive Management

• Early laparoscopic cholecystectomy (ELC) within 7 days of symptom onset is the gold standard treatment 1, 3
• The optimal timeframe for ELC is within 72 hours from diagnosis, with possible extension up to 7-10 days from symptom onset 3
• ELC is associated with:
  • Shorter hospital stays
  • Quicker recovery
  • Lower overall costs compared to delayed intervention 1, 2
• If source control is complete with cholecystectomy, no postoperative antimicrobial therapy is necessary for uncomplicated cholecystitis 1, 2

Management of High-Risk or Unfit-for-Surgery Patients

• For patients with prohibitive surgical risk, consider:
  • Percutaneous gallbladder drainage (PGBD) as first-line alternative 5
  • Endoscopic gallbladder drainage (cholecystoduodenostomy or cholecystogastrostomy) as second-line alternative 5
  • Transpaillary gallbladder drainage as last option 5
• After PGBD, delayed laparoscopic cholecystectomy should be performed after at least 6 weeks in patients who recover from conditions that previously contraindicated surgery 5
• For permanently unfit patients, gallbladder drainage may be considered as definitive treatment 6, 5

Special Considerations

• In patients with concomitant choledocholithiasis and cholangitis, evaluate the common bile duct with MRCP 2
• Obtain microbiological cultures in complicated cases to guide targeted antibiotic therapy 2
• Prefer antibiotics with good biliary penetration (piperacillin/tazobactam, amoxicillin/clavulanate, ciprofloxacin) 2, 4
• For elderly patients, surgical management remains the standard of care rather than conservative management, as age alone is not a contraindication for surgery 1, 6

Complications and Follow-up

• Laparoscopic cholecystectomy complications include bile duct injuries, which are among the most serious 7
• Complications can be minimized through proper training and appropriate conversion to open surgery when needed 7
• Regular follow-up is recommended after cholecystectomy to monitor for complications 2