Treatment of Cholecystitis
Early laparoscopic cholecystectomy (within 7-10 days of symptom onset) is the treatment of choice for acute cholecystitis, resulting in shorter recovery time, reduced hospitalization, lower hospital costs, fewer work days lost, and greater patient satisfaction. 1, 2
Diagnosis
- Acute cholecystitis is diagnosed based on clinical features including right upper quadrant pain, fever, and leukocytosis, supported by imaging findings 2
- Ultrasound is the investigation of choice showing pericholecystic fluid, distended gallbladder, edematous gallbladder wall, gallstones, and Murphy's sign 2, 3
Initial Management
- Start with fasting, intravenous fluid infusion, and antimicrobial therapy 4
- For uncomplicated cholecystitis in stable patients, amoxicillin/clavulanate or alternative antibiotics such as eravacycline or tigecycline can be used 3
- For complicated cholecystitis or critically ill patients, piperacillin/tazobactam or eravacycline are recommended 3
- Pain management should include opioids for severe pain, with acetaminophen and NSAIDs as part of a multimodal approach 5
Definitive Treatment
- Early laparoscopic cholecystectomy should be performed within 7 days of hospital admission and within 10 days from symptom onset 2, 1
- 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, 2
- For uncomplicated cholecystitis with complete source control, no postoperative antimicrobial therapy is necessary 1, 2
Special Populations and Situations
- For critically ill patients or those with multiple comorbidities who are unfit for surgery, urgent cholecystostomy is recommended 1
- Percutaneous cholecystostomy tube placement converts a septic patient with acute cholecystitis into a non-septic patient by decompressing the infected bile or pus 2
- For patients with high surgical risk (Charlson Comorbidity Index ≥6 and ASA-PS ≥4), percutaneous cholecystostomy should remain in place for at least three weeks 6
- If interval cholecystectomy is planned after percutaneous cholecystostomy, it should be performed at least six weeks after tube placement 6
Complications
- Early diagnosis of gallbladder perforation and immediate surgical intervention is crucial to decrease morbidity and mortality rates 1
- Gallbladder perforation is an unusual complication with reported incidence of 2-11% in acute cholecystitis and mortality as high as 12-16% 1
- Conservative management with antibiotics alone should be considered only as a bridge to surgery rather than a definitive solution due to frequent recurrence (up to 36% readmission rate) 7